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i Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved . OMB No. 2050039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST G& A I . 0 U 0 4 2 8 3 H :1 . 1 ( 800) 424 - I) AGO 016870138 16 (� "] O '! '] j� 1 1 !! 5. Gee l Na e and Mailing Address Generator's Site Address (if different than mailing address) V 1 y J V �J \J f� r17A I'LINPT 4 *1 1W, :2WO TUfti` ll 'INl ttu CID, Generator's Phone: Mi 47 !i ATAI 6. Transporter 1 Com3a y Name U.S. EPA ID Number t� l � 1-.11VI 3014MCWAi . F hYvif,L ? f r; t .; ' + ;? '1 7 0 3 Ali 7, Transporter, 2 Company Name U .S. EPA ID Number , t 70'- ?Y SY'�31 8. Designated Facility Name and Site Address U.S. EPA ID Number gr 24 30 E E 141310 YIIMA ikz 8663J65 Facility's Phone: ( `� " `.' ('' `1 ' ' r' . it ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes 1 - PKIN -KRA I-IAZ.f? f)Otr) VIA31TF' SOLID WAVER 1='11 :1 ER91) 1 2 LU 4. ENVIRONMENTAL HEALTH DEPART 7NT 14. Special Handling Instructions and Additional Information `:_ KlEaVGF.h10Y C20N1'A001 (, HE ?AIRK :i:- 9- 424�9300WOI- ,"; ft' 1;MINAI , 0E. E;llC< 1'3 tgAt:FCt'sp, 981, ; J. i _ . FF10FI114,# 96 :t 16k'rx 3tdit '�Al_E?ti7. F"APFII fllt ' A13r'Rf;I1?RIATE. F )Cj (: f'QLNF' ntt hl l' 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 govemmental 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 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 true. Generator'sfOfferor's Printedfryped Name Signature Month Day Year -r 16. International Shipments Z ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAcknowledgment of Receipt of Materials 2 Transporter 1 Printedfiyped NameJ Signature Month Day Year a Q [TFa r 2 Printed/Typed Name Signature Month Day Year h 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Typej j ❑ Residue ❑ Partial Rejection Full Rejection Manifest Reference Number: F 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V uQ. Facility's Phone: Lu 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z _ y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 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 Printedfiyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR' S INITIAL COPY