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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approve . OMB No. 2050-0039 ¢ UNIFORM HAZARDOUS 1. Gene ator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number /� ''}''' WASTE MANIFEST �I `y ' i OO ( I � 1 t ; ;t � L': L7l'1l -1 5. Generators Name and Mailing Addressr , I , ; r i1 Generators Site Address ( f different than mailing address) i ! ' ra tic.a 1874 iVha` 'f+ u fav``•-', T +:, f 'f jS't :::} Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number I . x,+ n1, 4 , t . , Fe<c5nf .l,'S7Ct , a1 ., ,' 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number t14 � c ..sr i !I tL�,iei:' t t �Jt� FacNtys Phonic 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 3. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.NoI. > i it ' t: st . r, tt r8 , � 2 par 3. 4. 14. Special Handling Instructions and Additional Information d } r ,8F�1 ft 4 b rfJ!1.. 1 r qr } .,^; r '(iir 15. GENERATOR'S/OFFEROR'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 and labeled/placarded, and are in all respects in proper condition for lranspod according to applicable international and national governmental regulations. If export shipment and l am the Primary Exporter, I rarity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I readily 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 quardly generator) is true. GeneratoeslOfferoes Prinle irryped Name Signature Month Day Year --r 16. International Shipments F ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: Transporter signature (for exports only): Dale leaving U.S.: ILL! 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintediTyped Name Signature Month Day Year O , Z Transporter 2 Printed/fyped Name . Signature Month Day Year a 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity El Type - ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number ZiS <a Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year ZZ c7 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: Ceriificabon of receipt of hazardous materials covered by the manifest except as noted in Item His Prin type Name Signature Month Day Year EPA Form 870022 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY