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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, " ? I ,. WASTE MANIFEST ,) = a �� S.ClnerabrsJ9r('eand Maill gAddress - Generalo's Site Address(if different than mailing address) iii ,,, tF -Irx.w�lld �Gd1iltftR?P.NE: U, I' �,kfr;ie A v1< Generatols Phone: 6.Transpoder i Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and SileAddress - U.S,EPA ID Number I1 , t'OI O(N`G'I NUh 11"!17 c)O!1 P I1 iitr'(I 4',AVI NO 1% Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No, ,Type— Quantity Wf.Nol. ,11'11 .t6;. 1.lk, /1,�Ylrll,4i',a41fS � Itlt7l,il?11bQ' I PJ;1I?04 Z 2. W LD __..._ 3. 4. 14.Special Handling Instructions and Additanal information ,r/ 3i'1 9P !O' firld.7i11I i i{ .,C I) t i'? 111 i 'L ItsI'I.0rl000:3692„' 'Fi 'i 4 OFPIATt ;'I' F0J-1 vJ;'IAI' _ 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 labelediplacarded,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 EPAAcknowledgment of Consent. I cedify that the waste minimization statement identified In 40 CFR 26227(a)(if.I am a large quantity generator)or(b)(If I am a small quantity generator)is We. Generators/Offerors Printed/fYped Name Signature Month Day Year --i 16.International Shipments r ❑Import to U.S. ❑Export from US Pod of enhylexit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transpoder 1 Prinled7fyped Name > Slgnalr j Month Day Year QTransporter 2 Printedlfyped Name Signature Month Day Year K 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantify ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181h.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) - Month Day Year 6 Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 Ila( '/ i I I'/- 2. 3. 4. 20.Designated Facility Owr{er or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedlfyped Name w Signature Month Day Year AC i EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR