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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) - Form Approved. OMB No. 2050-0039 - en t ( ID1N-"mjbser 2. Page e 1 of 3 Emergency l Response iPh 4. Manifest Tracking Number UNIFORM HAZARDOUS JJ' ( d o �-WASTE MANIFEST 'r 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) 71 ( ij 'v( t ; f114 � G cls ` ' tJ � t � Generators Phone: - U 4t 1 Z CJ h , el) .- 6. Transporter l Company Name ' -' Js U.S. EPA IDNumber 7. Transporter 2 Company Name n �11 ' 10 U.S. EPA ID Number 1 : tw (; Ylc� litvtYvll , tirF'I 'ti j ca ie7(/) lh .� r ` f �'� � C1�� CJO�S ( � c B. Designated Facility Name and Site Address _I ( . 7 Cr J cF•.`3 U.S. EPA ID Number al C , ( t�} jS 'J/ � < ! It yd(} 1 . 1 i Facility's Phone: 9a. 91h. U.S. DOT Descripfion (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HM and Paddng Group (I any)) No. Type Quantity WIN01. 1 aa �' .Y z 2. W 3. 4. t - 14. special Handling Instructors and Additional lnformabo j C % - ' � �' 15. GENERATOR'SIOFFEROR'S CERTIFICATION: -I hereby declare that the contents of this consignment am 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 regulators. If export shipment and l am the Primary Exporter, I certify that the contents of this consignment conform to She terms of the attached EPAAGknowledgmentof Consent. I certify that the waste minimiiation statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) CM am a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Iz Month Day Year 16, International Shipments ❑ ❑ `•----! f-. Import to U.S. Export from U.S. Pod Ofenby/exit -" z Transporter signature (for exports only): Date leaving U.S.: 17. TransporterAclmowledgment of Receipt of Materials 6E Transporter 1 Printedfryped Name Signature / Month Day Year O z Transporter 2 Pnted(Tr d Name /" _ Signature ��. Month Day Year /F 7`}' --- ,., 1 7 - G_ C ( l 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 J U LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year CD4 z 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. Certification of receipt of hazardous materials covered by She mandest except as noted in Item 18a Prinled7fyped Name Signature __ `- Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. —` DESIGNATED FACILITY TO GENERATOR