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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 1 . Gener for ID Number 2. Page 1 of 1 3. Emergency Respon Phone 14. Manifest Tracking Number , /� WASTE MANIFEST C7 1,- r s (; 1 00 01 P1 0 4 ,`g DAT 5. Generators Name and Mailing Address /: �. Generators Site Address (if different than mailing address) f fnt`e Ir .. f�.•"', to _ , /;43 ,iCi '. Generator's Phone: k-t '•_1S . 6. Transporter 1 Company Name U.S. EPA ID Number CL v ° t--}a c ( z ` t i fs T'r 1 r r trttt 2 ;_t, -,- 7. Transporter Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number t aaa' t d !, cr, IS.0 CF } ST rA µt Faclity's Phone: - � ,r ga 91% 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 WI NoL 1 LJ 2 r`ki ? , t: Ywt (D 3 4 t I i 14. Special Handling Instructions and Additional Information Jr L6. #° .• L 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmentare fully and accurately described above by the proper shipping 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 l am the Primary Exporter, I codify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneraloeslOfferors PrintedRyped Name Signature Month Day Year J 16. International Shipments - t— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Dale leaving U.S.: w 17. TmnsporlerAcknowledgment of Receipt of Materials � Transporter 1 Pdnted/fyped Name ! Signature Month Day Year QTransporter PnMed(fyped Name - Signature Month Day Year 04 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) U.S. EPA ID Number U a Facilitys Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year H a z to 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) - 2. 3. 4. 20. Designated Facility Owner or Operator: Cedifica ron 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