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Please print or type.(Form designed for use on elite(112-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pa I-of 3.Err�ergqn 4.-MantilestTracking Number <br /> 1 0 <br /> UNIFORM HAZARDOUSI t "L -S KS <br /> WASTE MANIFEST 02596488 <br /> 5.Generator's Name and Mailing Address Generators Site Address(ff different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter Company Name Con U.S.EPA ID Number <br /> _ <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name I and Site Address 114iftll)Number <br /> I <br /> Facility's Pho= <br /> 93. 9b.U.S.DOT Descripdon(including Proper Shipping Name,Hazard Cie$%ID Number, 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Grow Of any)) No. Type Quardity WL/VoL <br /> 3. <br /> 4. <br /> 14.Special Harding litatructi one and Additional Irdormation <br /> --4A .M41 r) TO' il'SIE <br /> 15. GENERATOR'SlOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fi*and accurately described above by the proper shipping name,and are classifted,packaged, <br /> marked and labeled1piacarded,and are In all respects In proper condition for transport according to applicable internalional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify M the contents of this consigment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste oWmization statement Identified In 40 CFR 262.27(a)Of I am a large quantity generator)or(b)lift am a small quantity generator)is We. <br /> Generatoes/Offeroes PrintedMiped Name Signature Month Day Year <br /> X., <br /> zi 1B.international Shipments <br /> I.— El Import to U.S. EIExport from U.S. Port of entry/oodt. <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> C5 17.Transporter Acknowledgment of Receipt of Materials <br /> U t <br /> Transporter 1 Nnted/Typd time Signature Month Day. Year <br /> ca <br /> Trardpoft 2 Pnnt9dqypedKanY9 r r Signalure Moth Day Year <br /> 18.Discrepancy <br /> 189.Discrepancy lnftadon Space i Quantity ❑Type FIResidue ❑Partial R.Jectir, F-I Full Rejection <br /> Manifest Reference Number. <br /> 118b.Altemate Facility(or Geri eralor) U.S.EPA U)Number <br /> L L FdWs Phone: <br /> LU 18c.SignaWof Alternate Fa,Cilily(or Generator) Month Day Year <br /> co 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1, 2 3. 4. <br /> 20.Designated Facility OwWor Operator.Certification of reoeiptof hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinoedRyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05):Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />