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Please Drint of Woe. (Form desioned for use on elite (17-nitchl tvnawritP.r ) ENA Form 81Uu-22 (Rev. 3-Ub) Nrevious editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone_711,1478342.32 . M(nifest Tracking Number WASTE MANIFEST 114 7 8 3 4 3 JJ K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address 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 No. Type HM and Packing Group (if any)) Quantity Wt.Not 1 ; 1. •I�? t!i.� y tQkZ,;.Vi ou4.w �.�3 tt; :!l:Lt!', i:.. :: I;.'_. O 7•s _ Z 2. W C7 - - I 3. 4. 14, Special Handling Instructions and Additional Information !,e4w fXY-Ec; 15. GEN ERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, 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 EPAAcknowledgment 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) (if I am a smelt quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year t` J 16. International Shipments ❑ Import to U.S. ❑ Export from U.S Port of entry/exit Z Transporter signature (for exports only). Date leaving U.S.: W 17. TransporterAcknowledgment of Receipt of Materials 12 Transporter 1 Printed/Typed Name Signature Month D�y Year n0 QTransporter 2 Printed/Typed Name Signature �_ _ _ Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type1 1 ❑ Residue ❑Partial Rejection Full Reaction Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U rat Facility's Phone: C3 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z 55 19. Hazarcous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year ENA Form 81Uu-22 (Rev. 3-Ub) Nrevious editions are obsolete. GENERATOR'S INITIAL COPY