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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS i . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. tdamfestTrackmg Number41 Do JJ WASTE MANIFEST 5. Generator's Name and Mailing Address ' Generator's Site Address ('d different than mailing address) Do If 1 so = 1 � It - D to Generator's Phone: foe > 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number Facilit es Phone: 8e• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit 13, Waste Codes HM and Pacidng Group (if any)) No. Type Quantity Wt.Nol. • It I Joe - / z 2• € l WDot It . 3. 4. I 14. Special Handling instructions and Additional Information _ ._ � t i I h •. 15. GENERATOR'SIO, fjEROR'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 an 19661lacarded, 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 Mile contents of this consignment conform to the terms of the attached EPAAcknowiedgmentof Consent. l; j I certify that )ho'v"rastoo te minimization statement identified in 40 CFR 262.27(a) (if I ani a,large quantity generator) or (b) (ifI am ar mail quantity generator) is true, Generator'slOfferor's Printedlryped Name t r on ay ear` j ) r . . � 1 ' t" t . signature `-'� DID t = � C. y f trlt� t � t ) AW r f . r �t ' ' I .. . Do, It D to j ooDID ..r 16. International Shipments ! C p_ ❑ import to U.S. ❑ Export from U.S. Port of entry/exit• 2 Transporter signature (for exports only): Date leaving U.S.: w17, TranspoderAcknowledgment of Receipt of Materials Transporter 1 PrinledlTyped Name , . Signature f T Month Day - Year . p ' t fr '1 L. ^' ti xrMonth Day Year i Q Transporter2 Printed/Typed Name Signature M 18, Discrepancy 18a, Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number V Facalitys Phone: Month Day Year W 18c. Signature otAitemate Facility (or Generator) a ti 19. Hazardous Waste Report Management Method Codes (t.e., codes for hazardous waste treatment, disposal, and recycling systems) 01 . 1 2. ` , 3. 4. Do 1i � r Fri signated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a /Typed Name Signature Month Day Year t EPA Form 8700 22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACIUTY'S COPY l i