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C�f�okt(�-J Ws, l til Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Ph rte r 4 Man fest Tracking Number f r f WASTE MANIFEST I:.': r r f . ! `- �. � !, JJK S. Generators Name and Mailing Address - . 1 IP - ' t r X. Generators Site Address (if different than making address) It tt 1'Y i`n ..e. 31 I i, i 1 li11, II txvfr. R: SIC 1 ( .'1.S f'? ;lt'. Generators Phone: �- K, -3 � ry .;�!-1fi 6. Transporter i Company Name U.S. EPA ID Number C , pti.tr'a ., r + - tr��_ I 1, irP[ ( 1�?�tL-�`st flfir F47F <_) �t;?.,. . ^-"'� ) trnlOnti , —. . 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Fa ility Name and Site Address U.S. EPA ID Number e 1 �tf 4 ti ! ' c LL.G f :ro!J0: t rr _;•. 10 G< t t3t�'rY ,.4s ht.^C Facility's Phone: 9a. 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 (if ani No. Type Quantity WI.Nol. 1 t r` -;-Ka r c 7, 1;1 o - � Z 2. W cD 3 i 4 1 - 14. Special Handling Instructions and Additional Information 0 ufntcill C I , 4 s t==Y fa rcr o074-c: r , 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and Iabeledlptacarded, 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 allached EPA Acknowledgment of Consent. I certify [hat 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 has. GeneratorslOfferoes Pdnted/Fyped Name Signature Month Day Year J 16. International Shipments i— ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: Transporter signature (for exports only): Date leaving U.S.: Lot V. TransporterAcknowledgment of Receipt of Materials Transporter l Prinled(Typed Name _ Signature .,-- -" „< Month Day Year Q Transporter 2 Prinledlfyped Name' Signature 1 Month Day Year K t— 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 '.. Zi U ua- Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year '.. Q Z 05 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item l8a Pdnted/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. - GENERATOR'S INITIAL COPY