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r� Pieese print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pa 1 of 3.Erne en Res se Ptxx a 1,00U1110194. .Manifest TrackingNumber UNIFORM HAZARDOUS ,t p°" WASTE MANIFEST a SKS 5.Generalors Name and Mailing Address Generators Site Address(if different than mailing address) Gen.eraicr's Phone: 5.Transporter r Company Name U.S.EPA ID Number 7 Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address r W.111'3 I:! I t j Ura I1_ U.S.EPA ID Number Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WIJVOI. IX d t l l ll .�,'flNaltF!GlilVf T` p >.r: r r, 4 11.1?.li i3 -- a LLJ Z 2. 3. 2 11017 4. DEP RTM INITI--� i 14.Special Handling Instructions and Additional Information ..iii .,Y ;.a_:;:ra.',' ;,. int;},;....i.�: !j_-, iF:f�i'.�-�11E-f•�y'-.�.t i.(-Y�1 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are"and accurately described above by the proper shipping name,and are ciassifed,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslOfferors Printed/Typed Name Signature Month Day Year _ r 16.International Shipments :- ❑Import to U-S. ❑Export from U.S. Port of entrylexit: _ Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgement of Receipt of Materials t2 Transporter 1 Printed'Typed Name Signature Month Day Year O a Z Transporter PrintedFryped Name Signature Month Day Year Q 18.Discrepancy 18a.Discrepancy Indication Space ❑ Ouantityy [IT pe El Residue ❑Partial Rejection Fu'I Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V L Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) t lonth Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal.and recycling systems) LU 1, 4. F 1 20.Designated Facility Owner or Operator:Certification of receipt or hazardous matenas covered by:he manifest except as ncied in Item 18a Printed[Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S WiTIAL COPY