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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 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST x le GBF 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) t s4 ,1.t � Generator's Phone: t" 6. Transporter 1 Company Name U.S. EPA ID Number eel E - IlI - V ellrel 7. Transporter 2 Company Name U.S. EPA ID Number t f - : „ f �. v ; v� IJ 8. Designated Facility Name and Site AddressU.S. EPA ID Number xlee -, Ile V & of IV. . t Facility's Phone: gal 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 Wt.Nol. 1 . PA It > ' V'I i IV O « � - Z 2. w 3. 4. 14 . Special Handling Instructions and Additional Information , xp 15. GENERATOR'SIOFFEROR'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 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 attached EPAAcknowledgmepf of Consent. I certify 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.qu an-jity generator) is true. Generators/Offerors Printed/Typed N me, Signature , ' / . ' Month Day Year , F µt t � � 4 }S r r M � ' =J 16. International Shipments H ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S. : w 17. TransporterAcknowledgment of Receipt of Materials TranspoIVArter 1 Printedffyped Name Signature t Month Day Year O a. CL x a Z Transporter 2 Printed/Typed Name ,Signature % Month Day Year I ; Vel 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type - ❑ Residuej ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) c= , _, , . , , , ,, _ - F , . i U.S. EPA ID Number �- Facility's Phone: ; jt ; t Q - „c tS - � i . . , i . w 18c Signature of Alternate Facility (or Generator) Month Day Year ( Is 4 Z r at , ' 3 N19, Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recy ' terns 0 1 . 2. 31 61= 11vi has the al propriate n 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest excwtas noted in Item 18n Printedflyped Name Signature generator is Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR