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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. P,lanifest Tracking Number WASTE MANIFEST �; fit ) ;" ri ;i A a U 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) fi( blI(J ' ! F ? llr 0A Generator's Phone: 6. Transporter 1 Company Name U .S . EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U .S . EPA ID Number I IN Facility's Phone: 928 )3 4 vols C98 2 Lot 9a 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 WL/Vol. ii PI IC RA I-iAZPiPI;if101) Wf4k3loF . W1 -IL) S t:? ; i .'t10C+ l.,II f) Z 2. w C9 �� -. 3. r - � 0 3 ? 019 __ _ _ - a. ENVIRONMENTAI . - -- --- H ,ENCTH f� '- p,A.RTfi . _ NT 14. Special Handling Instructions and Additional Information r =. ftSf', ttrf fiIGY t2041"F,L' i : 0lC*IENi f F7f: ; 1 —!? (`8),'424 �r30is WOES 1oFR IN1 i CXRE:�o ( " t' fIC.' f li,f i a ;l . .tf �E ,.'. . t � 1. t tII.Y t' t' f f° t ! IPMr.` hiT f 15. GENERATOR'S/OFFEROR'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 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. Generators/Offerors Printed/Typed Name Signature Month Day Year . �i 16. International Shipments" t-- ❑ import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials j Transporter 1 P.rintedfTyped Name Signature Month Day Year Dow QTransporter 2 Pntited/Typed Name ' Signature Month Day Year F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U U<= Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UE 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