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lease print or type.(Form assigned for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pages : 3 Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST ,ia) .. ) .. t,'r,,•� .r'p .01; lir I t c ,. r s ':€ JJK 5.Gener t i's Npme dM dm dd ess Generators Site Address(if different than mailing address) P" Mailing _I I lif! al t r E: t ^urs tt 4/,--z,_ Generators Phone: 6.Transporter,1 Company Name U.S.EPA ID Number r .-irtal'„ . r. 1r1Pkr- i fsl;! ' i1::'s-'it.l 's 1;f;ir 0' ; {)_, ja:„ j 7.Transporter 2 Company Name U.S.EPA ID Number 6.Designated Facility Name and Site Address U.S.EPA ID Number 14311iI ,,r, klrt11'i' . �; i$i 31rti¢r t;t, ,.i Faciliys Phone: 3t ri(6it rtOtA '.. 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, IO.Containers 11,Total 12.Unit and Packing if an 13.Waste Codes HM 9 Grou Pf Y)) No. Type Quantity wt./Vol. V3. NA3 fi ,( A }j..G'tl `"il - [!-) � 1 W2 (D 3. 4. 14,Special Handling Instructions and Additional Intonation 1 t 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 labeledliplacarded,and are In all respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and l am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I caddy 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 quantity generator)is true. Genet10 ed/I'y ed NameSjgnature Month Day Year ' , i j cl V.. —r 16.Intemati aIS pmenfs ' F � _ El Impolt to U.S. ❑Export from U.S. x. Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter l Printedfryped NameSignature Month Day Year , RTransporter 2 Pnnte fflyped Name r' Signature Month Day Year K h 18.Discrepancy 18a.Discrepancy Indication Space ❑Type ❑Residue ❑Full ❑ Quantity T e ❑Partial Rejection Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Zi ',.. U LL Facility's Phone: w 18c.Signature of Alternate Faciffy(or Generator) Month Day Year a z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 Printed/Typed Name Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY