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s print or type.(Form designed for use on elite(12-pitch typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Traddrig Number WASTE MANIFEST �f L X7 /l'— c. :� ' -7 7 , 0 ,r,0 77 6 MWI 5.Gener"s Name and Mad' Add Generators Site Address(d 'erent thanma14 address) ZL4 I 116 /6 qa Its/7�. S l�c.•�l/r; l_ fJ �'/r�7�s Generators Phone: B.Transporter 1 Com Name U.S.EPA ID Number / 7.TrwsWW2 Company NIIrne U.S.EPA ID Number 3.Designated FFaacid Name and Site Address U.S.EPA ID Number c= Facility's Phone: i a ga, 9b.U.S.DOT Desc ption(including Proper Shipping Na ,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(d any)) No. Type Quantity Wt(Vol. i 2. i 3. 4. 14.Special Handling Irratmlogns and Additional Inforrrtabon - u-7 15. GENERATOR'SIOFFEROR'SZERTIFICATION: I hereby dec are that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and lalbeled/placfded,and are in all respects in condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the corrtents of this consignment conforr i to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 FR 262.27(a)('d I am a large quantity generator)or(b)(8I am a small quantity generator)is true. 3eneratoesrOfferors Printedrryped Name Signature Month Day Year 16.In 'onai ipments I t. El Import to U.S. ❑Export from U.S.` Port of entry/exR: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment ofReceipt of Materials -ransporter 1 PrinteCyped Name Signature f Month Day Year 'lg -\( ,a ki Zo 1 //,- / rranspoder Z Prinled/TypedName S e Month Day Year J 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number -acllws Phone: ft.Signature of Altemate Facility or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,cod for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. t ~ .0.Desgnate Owner or Operator:Certification of r' ipt of tzardous materials covered by the manifest except as noted in Item 18a �rinted/Typ e ` y Signatur Month 09Y / U ;orm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR