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Fnrm Annrnved. OMB No. 2050-0039 Please print or type. (Form designed for use on eute (12 -pitch) Lyp 2. Pagel of 3. Emergency Response Phone MOanifOest Tacking Number UNIFORMHAZARDOUS 1.'Generstor ID Number - DAT WASTE MANIFEST _ -` " . S. Generators Nam and Mailing Address Generators Site Address (d different than mailing address) GeneratoPs Phone:' U.S. EPA ID Number 6. Transporter 1 Company Name 7. Transporter 2 Company Name U.S. EPA ID Number 8, Designated Facility Name and Site Address U.S. EPA ID Number Fadlity's Phone: Ba. go. 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 WLA7ol. 99 Z 2. t9 3 .. 4. ; 4 14. Special Handling Instmctiona Bhd; cxitidnal Information ,. i'.i_F xi:.�. Ori ,LaiO 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, and are classified, packaged, marked and Iabeadlplacarded, 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 terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator)or(b) (81 am a small quantity generator) is true. GeneratorslOffears Printedflyped Name Signature Month Day Year F 1 .Intemational5hipmenLs -Ll Import to U.S. ❑ Exportfrom U.S. Pod of enhylexit: Z Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials ad Transporter 1 PdntedfFyped Name Signature Monlh Day Year z Transporter 2 PriMadlfyped Name .Signature Month Day Year Q Discrepancy i18. 18a. Discrepancy Indication Space ElQuantity❑ Type [:1Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. IStu Alternate Facility (or Generator) U.S. EPA ID Number J V rai Facility's Phone. Month Day Year w 18c. Signature ofAhemate Fadlity(or Generator) a z m19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 4. 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the mangest except as noted in Item 18a PimedRyped Name :! 7 Signature Month Day Year '. n.-.,�srwt�r� �w nrr IT\/T!1 /'!CAtGO ATr1C EPA Form 84OU-22 (Rev.:wb) Previous eamons are outdone.