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Please print or type, (Form designed for use on elite (I2 -pitch} typewriter.) 11111ORM IAZAI111011 [. Generator 11J Number 2. Page a WASTE MANIFEST 5. Generator's Name and Mailing Address r; 7� Generators Phone: 6 Transporter 1 Company Name 7. Transporter 2 Company Name S. Designated Facility Name and Site Address in �72 Facilitfs Phone: ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, HM and Packing Group (if any)) 1V ?J V LLF ZZ 2. LU 0 1 4. 111111111111111111111111111111111111111 0065208 a 5 S K 6 Form Approved. OME1 No, 2050-0039 Emergency Response Phone 4, Man fast Tracking NU in-ber ()0 6520885 _aCSJ aerator's Site Address (ii'different than Mailing address) U.S. EPA ID Number I CIT 6 "'rl H. -I IT1:t7._,'_ 4." 7h; i Ti rC.At. t?f let P T P ?:Nrhli'i' [;Cj f'i 15. GENERATOR'SIOFFeROR'SCERTIrrCATION! I hereby declare that the contents of this consignment are fully and accurately described above by the proper s6pping 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 EPAAckriowledgmant of Consent. l' certify that the waste minimization statement identified in 40 CFR 262.27(a) tiff am a;arge quantity generator) or (bAifl am 4 small quantity generator) is true. Genera es/Offerors Print /Typed VSignature Day Year V, i / Ae-x 0 ecvu i- Wt � 16. interna ional Shipments I 1.— 1:1 Import to U.S. E]Bpcd from U.S/ Pod ofentry/exit: Transporter signature (for exports only); Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Trst7poer 1 PrintedfTryNnme 0 .7 --p Signatur MonthDay Year 0— I Trenspo ter 2 Prin d1Typ me Signature Month Day year &-i's __ � I 1 18. Discrepancy 18a. Discrepancy lr&aflan Space 0 Quantity El Type ❑ Residue ❑ Partiat Rejection E]Full Rejectian 10b. Alternate Facility �or Generator) Manifest Reference Number ate EPA ID Number rQi F.dilitys. Phone: 16c. SignpWre of Alternate Fadilty (or Generator) Month Day Year 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems-) LLJ 1 A// V/ 20, Designated Facility fler or Operator: Cerfificafion of receipt O!Iwardous materials coven y the manifest except aux noted in Printed ed Name Signature EPA Form 8700-22 (Rev, 3-05i Previous ediflons are obsolete. 7DE5IGNATED F 4, M "� - TV V1 K'W_ 'I'M ra r". iIT 101 VA i PjcCL, I p; 10. Containers 11. Total 12. Unit No. Type 13. Waste Codes Quantity WuVal. I CIT 6 "'rl H. -I IT1:t7._,'_ 4." 7h; i Ti rC.At. t?f let P T P ?:Nrhli'i' [;Cj f'i 15. GENERATOR'SIOFFeROR'SCERTIrrCATION! I hereby declare that the contents of this consignment are fully and accurately described above by the proper s6pping 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 EPAAckriowledgmant of Consent. l' certify that the waste minimization statement identified in 40 CFR 262.27(a) tiff am a;arge quantity generator) or (bAifl am 4 small quantity generator) is true. Genera es/Offerors Print /Typed VSignature Day Year V, i / Ae-x 0 ecvu i- Wt � 16. interna ional Shipments I 1.— 1:1 Import to U.S. E]Bpcd from U.S/ Pod ofentry/exit: Transporter signature (for exports only); Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Trst7poer 1 PrintedfTryNnme 0 .7 --p Signatur MonthDay Year 0— I Trenspo ter 2 Prin d1Typ me Signature Month Day year &-i's __ � I 1 18. Discrepancy 18a. Discrepancy lr&aflan Space 0 Quantity El Type ❑ Residue ❑ Partiat Rejection E]Full Rejectian 10b. Alternate Facility �or Generator) Manifest Reference Number ate EPA ID Number rQi F.dilitys. Phone: 16c. SignpWre of Alternate Fadilty (or Generator) Month Day Year 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems-) LLJ 1 A// V/ 20, Designated Facility fler or Operator: Cerfificafion of receipt O!Iwardous materials coven y the manifest except aux noted in Printed ed Name Signature EPA Form 8700-22 (Rev, 3-05i Previous ediflons are obsolete. 7DE5IGNATED F 4, M "� - TV V1 K'W_ 'I'M ra r". iIT 101 VA i