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Please mint or h0p(Farm Mqinnpri fnr um nn alit& h--if-1 4 tt H Form 8700-22 (Rev. 3-05) Previous editions are ODSOiete. ID,E,3�11C.'WrED FAC11UTY UNIFO4!=RDOUSI�Ge;nerator ID Number I V1111 rWV1VVVU. VIVIDy4u. ZUZ)U-uuJU I C(._l 14. M.nffmt Tr.,kin _EST onse Phorm 9 Number WASTE MANIFEST -3 011279771 JJK I neMrs NaTa,nd Mailing Address , GVo s t -f- es Site Address (if different than mailing address Generators Phone: 6, -Transporter 1 Company Name U.S. EPA ID Number D D 7. Transporter 2 Company Name U.S. EPA ID Number t,,l n qn1A #,Oesptad Facility Name and Site Address I, I _` I'll 11 U.S. EPA ID Number c" iY 7� L 11-1 E-ALTH I- FacilitysPhone: P- IT 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13, Waste Codes No. Type 0 1 z —Y W 2., � U L 4.. 14. Special Hand�finj Instructions and Additional Infoation 4 7 T -P 07 0 'S4 ffi t, et 1.1? t- �1. F4) 4:A? 15. GENERATOR'SlOFFEROR'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 labeled/placarded, 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 small quantity generator) is true. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year c 16. Intern` Shipments 0 Import to U.S.' El Export from U�IS Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: LW U 17. Transporter Acknowledgment of Receipt of Materials 0 Transporter I Printed/Type Name Signature s fr Month Day Year Z Trans 'IPI yped Name Signa Month Dpy,. Y "ya 18. Discrepancy 18a. Discrepancy Indication Space 0 Quantity El Type El ❑Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: uj 18c. Signature of Alternate Facility (or Generator) Month Day Year !R Z 19. Hazardous*aste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1. #/0 f 4 2. 6 S 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prkn4edlTyped Name Signature Month Day Year 7 tt H Form 8700-22 (Rev. 3-05) Previous editions are ODSOiete. ID,E,3�11C.'WrED FAC11UTY