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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 4 UNIFORM HAZARDOUS 1 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number qq WASTE MANIFEST t 1 I [ , , t k'st t r (� r l 1 � � OOG I d . t„H 5. Generators Name e dMai ng Address 1 I II i I (t 101 VUJJ s'7s Generators Site Address ( f different than mailing address) UtIit 1 .3f r , !C If tr73VIL lkvi, qr_� ;: 1traC Z :tl I h If Ali Ila jr. II -7r% ”%3'�dl -E't D4 x iYtCr;> Generator's Phone: 309 - 6. Transporter 1 Company Name U.S. EPA ID Number I rd .. titHn ( t _��. , :vrt r );i FtS f'} fC rlC »tt [ fC) , Sr61 fY)J3t , - _ / :?VIIJ � r�'. r' 7. Transporter Company Name - U.S. EPA ID Number 8, De Snoted Facility N nd Site Address U.S. EPA ID Number r c r3l-lat [ cn .lr, e LL'; If 1C) � t Urif'IY cn r'. d ,;;tri Jss;r . Cta :; F "t Facility's Phone: go. 91h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit _ 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Ar.Not o - z zlf _ , .,. � . r .,_ Iv� G -. .Ia , It_oG ( tl . s h ;dtv . n, . .. ��: << 1, ED i _ C 47:1 (Df) `I :4 3 ti ,'tJ� r it _. : :L.1.6 e � fr :, rlG t � lir G , (,€= Iv 1 . .r =CA , S, ,' . f(( 4 1 '14. Special Handling Instructions and Additional Information,(_ � ttI: cd"rY ( tcVr �C �Irte9t _ 1 C - 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, add are classified, packaged, marked and labeledlplacarded, 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 261 (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneratorslOfferofs Printed/Typed Name Signature Month Day Year 16. International Shipments j— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials � Transporter PrintedlTyped Name (�- F,- Signature/; - - Month Day Year QTransporter 2 Printedr'fyped Name IrSigndur /.. Month Day Year K 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Pull Rejection Manifest Reference Number: r 18b. Alternate Facility (or Generator) U.S. EPA ID Number Zi V , r¢i Facilittys Phone: w life. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1 . 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY