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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 7 . Gener for ID N merb2. Page i of 3. E g y R spo se Phone 14, Manifest Tracking Number p WASTE MANIFEST CJ, k t. , >k � � rf t fc { r;; tr Y DAT - 5. Generators Name and Mailing Address / I l ILr ( ri'(xrr;,, Generators Site Address (if different than mailing address) 6, 1.ISMrC11 r , it . AAL Generators Phone: li<ri'-3'..' 2 ;4a1J ' 6. Transporter 1 Company Name U.S. EPA ID Number In?xi ttz+..tt;t _ , r, a.c . u . r( .. .i". r . , , -r.' ,. f . r,' $ 6 U 10� >f) r,fi:�CrOri 7 ;�7 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address - U.S. EPA ID Number t w .ia Eet x fu . > e r r rificrc>, t-f, Ct 3t 'tf:` t 'r"ii: �, SIOWZhE Fecllit)rs Phone: i1if+-T5'- Fir 9A6 go. 9b. 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 (it any)) No: Type Quantity WCNoI. C Z 2 1 t� t .�5. r7( t�, , Ycf t, t c nt� f .r � 111E F + r t. , t •� ) �� __� c7 3 4. i4. Special Handling Instructions and Additional Information z „ �. i t . ,ri 1 � At t rz. =i. ) � P (fif Car 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name, anal 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 I am the Primary Exporter, l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement dentified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. GeneadoeslOfferors Printedrryped Name. Signature Month Day Year HA, 16. International Shipments 11 nation to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: lai 17. Transporter Acknowledgment of Receipt of Materials w Transporter 1 Printedffyped Name Signature Month Day Year O A ... . CIA. _ . GTransporter 2 Prinledrryped Name Signature Month Day Year K t— 18. Discrepancy 1 Be. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number 18b. Alternate Facility (or Generator) U.S. EPA ID Number Z3 U LL Facility's Phone: da IRa Signature of Alternate Facility (or Generator) Month Day Year a i z c9 19. Hazardous Waste helped Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 3. 4. 20. Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by the manifest except as noted in Item IBe PrintedlTyped Name Signature Month Day Year I EPA Form 8700-22 (Rev 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY