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PI a print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number UNIFORM HAZARDOUS . he) � '' `�91, ` JJK WASTE MANIFEST L 0`(I) ) Ift4x- r Vw 5.Generator's Name and Mailing Address ?c34;,r,T o..} ;i` `d Generators Site Address(if different than mailing address) ..;T`..r.ir..•...., -�t._�r_�:. ..Te.�t'.Jc.a.7�..! f,r3 �t i;t.t'iw Generator's Phone: ; L t. •f �` U.S.EPA ID Number 6.Transporter 1 Company Name 11;!.,13 r-' 7. ransporter 2 Company.Name U.S.EPA 10 F Number ry tFdf'�`�ffi 4 ' a;'!•} t :{ /' l '`--''1 A (!`1�r 1'f•�6�r J ,J'\. '`�t..,�'v. „'��' �,.✓6�.^ .+}' `�l!l �._I�• E��t.ti..tr{.-F�!•C...�„ l ,--- 8.Designated Facility Name and Site Address t:. G C'' °°v '� 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 HM and Packing Group(if any)) No. Type Quantity WtNol. t k 1.Ixi _•�__.._..._._-.. r"'o?•1 �?t;'L.Gi4 i:-k'<..cy it L,.J�, -r11T-T '>b{.t C_.r'1:i X3 ii.%:cC,',•.r7-,a Z 2• LU d. t,.__,...._.. I p f 7 i I 3. E E I 4. 14.Special Handling Instructions and Additional Information •. t..,,;i.: ✓;r¢� �-:2t:� ft 1' t' >>-gC�:t_r,.'ti Cc.u,'"4'' C<;,r, f-.c .YK�"� .,�.'.;,j`du�}j� SrO ..� '!`; -. G.t Z S ��'�:,1�'P` 15. GENERATOR'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 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 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)(if I am a small quantity generator)is true. Generators/OB rods Pr nted(fyped Nae Signature C .. Month Day Year ..L 16.IntemationallShipments Port of en by � ❑Import to U.S. ❑Export from U.S. /exit: z Transporter signature(for exports only): Date leaving U.S.: LY w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PHt /ryped Na j), f Signatur -� ,�„r f M Da Ygar f € 1 a P` Z Tran orter 2 PHntedrryped Name Signature q Mon Day ear PC s t .e f�4 RC1 1r� 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuli Rejection tIE REFERENCED WASTE WAS RECEIVED.HANDLED AND SPORED FOR SUBSEQUENT OF1'STTE iSPOSAL.TREATMENT OR RFUSS CROSBY k OVERTON.INC OPERATES THE PACIlWlf rence Number: 18b.Alternate Facifif giy'eh€t�t'bhj - A TVGetT U.S.EPA ID Number :3 111 111E EN tRONMENTAL PROTE(710N AGENCY IN ACCORDANCE WITH TIIE PROVISIONS OF V I[C RESOURCE CONSERVATION AND RECOVERY ACT OF 1976 TOGEITIER WI•III APPLICABLE Q f,DERAL AND STATE REGULATIONS. CROSBY k OVERTON HAS ALL OF TILE NECESSARY ri Facility's Phone: WAEX&ND ALL 10 e✓ W 18c.Signature of AI I��r Generator) Month Day Year ZZ 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W q 2, D ' t 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the:manifest except as noted in Item 18a Si natu Mont Dayr, Year. PrintedfTyped Name 9 ! EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR