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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB�l -0, UNIFORM HAZARDOUS '1.Generator ID Number 2,Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST �. 3 ,.tip_ r 44 9 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone ', 6.Transporter 1 Company Name.. U.S.EPA ID Number —,, -'91 1k.w 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address", U.S.EPA ID Number 41'k1.. k f1 elit. - . of 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 Wt.Nol. 1. ;: u Z 2. ; w C) t 31 y ) i 4. 1 i p i g 1 14 Special Handling Instructions and AfldrtlonaI Jnfprntation A-77 "i Ia - t 3 ` � �r-a:4 a e- - ys_8t �,vIf, F .rd(,:µ ,..r., i _c'-0 f.�,.t�r, e 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 EPA Acknowledgment of Consent. I certifythat 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 true. Generatoes/Offeroes Printedfryped Name Signature Month Day Year, 16.International Shipments I- EJ import to U.S. ElExport from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: at: 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Printedfryped Name a } ( Signature $f t Month Day Year CL QTransporter 2 Pnntedfryped Name Signature r'° " V ' Month Day Year F- 18.Discrepancy ❑Type 18a.Discrepancy Indication Space ❑ Quantity T e ElResidue ❑Partial Rejection El Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3. 4. 411 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped NName Signature Month Day Year EPA Form 8700-22(Rev. i-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY`i