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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 WASTE MANIFEST 0� .` .g r v ��e JJ ». 5 =: f Generator's Site Address if different than malls address Generators Name and Mailing Address r I'� r R i Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 4r ^ ErP1 C-T NIVIF1<1TA.i.'3F 11C li+;,'. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address�� U.S.EPA ID Number lJO.. E N,0.1EAIT.4L SERti,r tC VVIF.i�-T 3r+.CR,1kME14T0,Cee- C4%9'I Facility's 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.Nol. of 0 I 3. � I 4. 14.Special Handling Instructions and Additional Information + d ` ? ✓ F�' Ks iQLER.a 1O BE TRAINED AJV0 SI-=R.}';~' V. F—D PPE. Ct:N`M.ACT0R: RA 109 i'.K4A8`iONMENVL SEPVIGES 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 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 true. Generator's/Offerors Printed/Typed Name f/ Signature 7 Month Day? Year f J 16.International Shipments _ 4! F 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature ' /"�✓ Month Days Year �t'J J t�`• a zQ Transporter 2 Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Rejection El Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year d ' z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU G 1. 2. 3. 4. ) I-)t 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 `7 Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY