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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generad 2.Pae f 3.Eme 7encyft;A0 ' <br /> Manifest TraeldnNumberWASTE MANIFEST ` l2g791 9 `� '�° 001 0 l576 FL <br /> 5.Generator's Name and Mailing Address Generatoes Site Address(if different than mailing address) <br /> Lu=dte ReWl LENS RS 4135 <br /> !,04 � 0$11 P1 clo 144 a P ON' 7 <br /> Generator's Phone: 2094774114 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ENM - WAL LJ'1`t0N8 OKM7=128 <br /> 7.Transporter 2 pony Name U.S.EPA ID Number <br /> 8.Designated Facili Name and Site Addregs U.S.EPA ID Number <br /> W=0 STAMUM SS VE MOD.981123391 <br /> GTY,MO"129 <br /> Facllitys Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) NO. Type Quantity Wt.Nol. <br /> (X X ''Waste m organic,r�.o s, Propyl / P 362 1 <br /> 0 Alcohol, Coating),4.1 , UN1325,/RQ OF <br /> z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> i� <br /> 14.Special Handling Instructions and Additional Information " <br /> 1.)AppmvvJ-#:,AE648W,ERG 0195 y <br /> 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 classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporrte4 I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of•Consent. <br /> I certify,that the waste minimization statempAt identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b)(d 1 am a small quantity generator)is true. <br /> Gene nor not yp Nam r Signaturer r r on ay Year. ' <br /> J 16.International Shipments <br /> Z r-1Importto U.S. ❑Export from U. . Port of entrylexit: <br /> Tran iter signature for exe2rts only): Date lea'22 U.S:i, •. <br /> W 17.Transporter Acknowledgment of Recopt of Materials <br /> Transporter nntedlfyped a Signature on ay Year <br /> a <br /> Z Transgorte Printed/Typed Name Signature ay Year <br /> 18'Discrepancy .0 <br /> t8a:Discrepancy Indication Space - ❑ Quantity w ,❑Type ❑Residue ❑Partial Reston ❑Full Road.,, <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> CJ • <br /> tui Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(es Generator) t, Month Day Year <br /> Q <br /> Z _ <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C2 i. /i ( t 2. 3. 4. <br /> f( <br /> 20.Designated Facility Owner or Operates:Certification of receipt of hazardous materials covered by the manifest eitcept as noted in Item 18a <br /> Print;yped Signature Monty Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 10404.1864 . <br />