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Please print ortype.(Form designed for use on elite(12-pitch)typewriter.) .Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator IDNumber 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST �,4 } 1 JJ K a ,. 5.,Generatoes Name and Mailing Address Generator's Site Address(if different than mailing address) P _. .. - f r , Generator's Phone: 1�4 6.Transporter 1 Company Name U.S.EPA ID Number . . . 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 3 Facility's Phone ga. 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 any)) No. Type Quantity WtNol. W 2. s 3. 33� 4. I 14.Special Handling Instructions and Additional Information 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 transport according to applicable intemational and national governmental regulations.If export shipment and t am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or(bp(if;am a small quantity generator).istrue. GeneratoestOfferoes PrintedfTyped Name Signature;'; Month Day Year 16.International Shipments Z1-1 Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year CL to ' Za Transporter 2 PrintedlTyped Name Signature Month Day Year h 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Typej j ❑Residue Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V tQiFacility's Phone: W 18c.Signature of Alternate Facility(or Generator} Month Day Year Q1Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700-2 (Rev.3-05) Previous editions are—62ete. DESIGNATED FACILITY'S COPY