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._ . _ III.��I � I � IIIIIH�II��I�I��I �IIIIIfl �� Please print or type.(Form designed for use on elite(12 pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 01139284 F L E 5.Generator's Name and Mailing Address Generator's Site Address('d different than mailing address) Generator's 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,l0 Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Z. } LLJ f ` " W 2. # # a I 3. 3 t i 4. 3 f t 14.Special Handling Instructions and Adaitional Information , 15. GENERATOR'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 classed,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 W quantity g rator)is true. Generator'slOfferor's PeriintedlTyped Name Si5nature ` Month Day Year 7C ) ! 1International Shipments z 6: ❑ Import Export from U.S. Port of en t Im rt to U.S. ❑ ..� Transporter signature for exports onl Date IL `[1 S.: 17.Transporter Acknowledgment of Receipt of Materials LLJ Transporter 1 Printedlfyped Name ignature w0Month Day Year r: Transporter 2 Printed/Typed Name nE: Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication SpaceF-1Type ❑ Quantity El Residue El Partial Rejection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number U LL- Facility's Phone: W 18c.Signature of Alternate Fadlity(or Generator) Month Day Year a Z a--i19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU L 1. -- 2. 3. 4. r 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PdntedfTyped NameSi Signa g t Mo Day #. 6- turd nth Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. 3;84'.-:,NcTi0 FACILITY Dr STszATKO�SULs> iS. a'?k-£.fix.SlzpfDl