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Please print or type.(Form designed for use on elite(12 pitch)typewriter.) Form Approved.OMB'N UNIFORM HAZARDOUS 1 Gen"r 14 j lumber a n 2.Page 1 of 3 Emergency Response Phone 4 Manifest�t Tracking Number WASTE MANIFEST rw.. < ,. :, . , ., �� JJ ; 5.Generator's Name and Mailing Address Generatoes Site Address(if different than mailing address) v Generator's Phone 4—— 6.Transporter 1 Company Name U.S.EPA ID Number t ,r. >g 7.Transporter 2 Company Name U.S.EPA ID.Number 8.Designated Facility Name and Site Address, U:S.EPA ID Number �.. .. : U.S. £ .. Rf" ( Sa 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 Quanfity Wt.Nol. <', 173,E t%ofx�' v t fit , Z 2. W 3. j 4. F t 14 Special Handling Instructions and Additional Information 1 '� orf; 091 ?; sf . .�`da„r 'E:44-'A",fFP°ti'e.,z a'`rna,,. 15. GENERATOR'SfOFFEROR'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 EPAAcknowiedgmentof Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(KI am a.small quantity,generator)is true. GeneratoestOfferor's PdntedtTyped Name Signature Month Day Year sr —J 16.International Shipments ElImport to U.S, ❑Export from U3,-��``� Poror t ofentry/exit: Transporter signature(for exports only): Date leaving U,S: IX 17.Transporter Acknowledgment of Receipt of Materials r t2 TtaFporter 1 PnntedtfypedJlamexe.-Sig tui f ` M�It Day Year, 0w A x' 1 aTransporter 2 Printed/Typed Name "Signature Month Day Year H 18,Discrepancy 18a.Discrepancy Indication Space E] Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J t) LL Facilitys Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z CD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. t a 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature 9 Monih Da Year EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY