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i Please print or type.(Form designed for use on elite(12-pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST r 5 Generators Name and Mailing Address - FLE nr „ Generator's Sfe Addrass(ddifferent than malting address) Generatols Phone: - •�'!° _ _ ransp_o_rt_er 7 Company_ame - U.S.EPA tD Number 7.Transporter2Company Name - "" U.S.EPA ID Number 8.Designated FaciliTy Name antl Site Address - _ U.S.EPAID Numher DOT Des;Pbon(including Proper Shipping Name,HazardClass,ID Number, HM'; and Packing Group(dany)) 0.Containers 11,Total 12,Unit 1 o. Type Quantity WLIV01 13.Waste Codes UJ uJ I 4. r 14.Special Handling InsWctionsantl Adc1conal Information r 15. 6ENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accu atelydescr-bed above by the proper shipping name,and are classified,packaged, marked and labeledlplararded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If exportshipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cons IN. 1,certify that the waste minimization statement identified in 40 CFR 262.27(a){H I am a large quantity generator)or(b)(if a small quantity generator)is true. enerator'sl eroes Printed yped Name igna ure .5 gvz- �'E.-LEN /2 / on ay aer i18.International Shipments 1- 11 Import to U.S. ❑Export from U.S. P rt of entiylexil: Transporter signature for exports onl W 17.TransporterAcknowletlgment of Receipt of Materials D to leavingU.S.: Transporter 1 Pnntedll'yped Nam�W.�/ Signature O Sv1��r r'9-LSC till y Year �O9 96 /� a Transpoder2 Pdnted/Ty a ignature Doth Day Year 18.Discrepancy t' 18a.Discrepancy Indication Space ❑Quantity Type ❑Resid ❑Partial Rejection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest R stance Number: � U.S.EPAID Number U Q LL Facili s Phone: Bu I K.signature of Altemate Facilily(or Generator) - .Month Day Year z F 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,die , LU t 2 poral,and recycling systems) - 3. I 4, 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted?in Item 18a rin N or rgna �� "h Da Year , EPA Form 8700-22 v,305)previous editons—WI ESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)