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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 sr ,Ri 0?WASTEMANIFBST + d P k. {;go JJ 5.Generrp(QrlsiMe 1pn,d,f)1ai){",q,dd,gs III,a a� Generators Site Address(if dlgerent than mailing address) I i rjj -AllI I' i4 ii. in It, Generators Phone: 6.Transp?'MlbCp1,lI➢�n�lN-��a tF,f:=i 1 t..'g.E4'v r<,�i;li U.S.EPA�DINumbeJ t, ,! r ( , 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designg le Fapiity Kamp and Sda,Add(e(Stsf{; U.S.EPA ID Number Oi4ro J'x;;4.;Esru�,`10 6,1i rr lcilf_ Facllilys 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./Vol, a. 1 <r Id-K;,: t. „A', .i jd"'Writ>11i .r'0A ( 00 r0i It , 1'1'W; t'b O Z 2' 4. 14.Special Handling Instructions and Additional Information rlr t?a'.IS.elttlll,-r<'i i,Hkl( t ..il: ikit i r„s U . , tr J fl', !i 'Pl-.` , 11I• I , of_,c r A'i 1;JPA1 ltAlti .;l"lf' + X 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpping name,and are classified,packaged, '.. marked and labetedlplacarded,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 EPA Acknowledgment 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 quantity generator)is her. GeneratoestOfferoes Printed/TypedName Signature Month Day Year 16.international Shipments z ❑Import to U.S. ❑Export from U.S. Ped of entry/exit: Transporter signature(for exports only): Dale leaving U.S.: w 17.TranspoderAcknowledgment of Receipt of Materials Transporter i Printed/Typed Name ' Signature ,:- " . Month Day Year za Transporter Printed(Typed Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑T e yp El Residue ❑Partial Rejection El Fell Rejection Manifest Reference Number: 181h.Alternate Facility(or Generator) US.EPA ID Number J U w Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q P. z 19.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:Car igcation of receipt of hazardous materiats covered by the manifest except as noted In Item 18a Pdnted7Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY