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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator IQ Number 2.Page 1 of 3.Emergency Response Phone 4.Mam ostTracking Number WASTE MANIFEST 6, _ -- 009550117 JJ K 5.Generators Name an!Mailing Address Generator's Site Address(if different than mailing address) Generatods Phone:2-79455--,447,- 6.Transporter 1 Company Name U.S.EPA 10 Number 7.Transporter 2 Company Name U.S.EPA IQ Number 8.Designated Facility Name and Site Address _ _ U.S.EPA ID Number Facility's Phone: t='- 4 -'r l�• 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. Typo Quantity Wt.Nol. 1' -:'A TE LIQUID • __I''= .j'V'• t�f.1 _ v C 2. LU 0 3. - 4. 14.Special Handling Instructions and Additional Information j [� E.F. �;rO%T -�CTOP Fr,` C(i+d�'r�Sfii:.sc{,I7+, C SHOULD E-E ;EJ . ,r'.;� L��r-' s `;�nJ �rE 15. GEN ERATOR'SIOFFEROR'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 lerms of the attached EPA Acknowledgment of Consent. I cerlify 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 small quantity generator)is true. Generator'slOfferces PrintedlTyped Name Signature Month Day Year r 16.International hipments f �— ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports onl YDate leaving U.S,; CC 17.Transporter Acknowledgment of Receipt of Materials Fe Trans o er 1 rintedlT � yped Na Sign re Month Day Year a . r U) Transpo ter 2 PrintedlTyped Name naturg; Month Day Year H 18.Discrepancy 18a,Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 15b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. Tl--- Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED I L+L ILl7 Y TO DESTINATION STATE (!E REQUIRED)