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Pie as print or type, (Farm designed for use on elite (12-pitch) typewriter.) _ Form Approved, OMB No. 2050-0030 UNIFORM HAZARDOUS 1. Generator ID Numher 2: Page i of 3. Emergency Response Phone 14. ManifestTracking Number '.. WASTE MANIFEST �� ® � gipo " �''Z "q3 009 .400321 JJ K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) APAMA9K '7t'7-7(91 , 5a Gene�r a;-7o 8 Pho A 41-rap � � a - 6. Transporter 1 Company Name U.S. EPA ID Number Pk L� I CAKo1jtw77jgr 7. Transporter Company Name U.S. EPA ID Number " 8. Designated FacilityName and SHoAddress U.S. EPAID Number 6 aLp SKY ( , �n J, sPhohe��P741tBLt69 &4q �6 �'�✓� � - d ��4J ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Creep (if any)) 13. Waste Codes '.. No. Type Quantity Wt.Nol. A4 LM z 2. IF #w � y IF 3. €k) l 14. Special Handling InsWcBons and Additional Information , 15, GENERATOR'SfOFFEROR'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 governments[ 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 codify that the waste minimization statement Identified in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (fit am a small quantity generator) is flue. 10temes Name SkpIture Month Day Year FAY 116 � 16. International Shipments z ❑ Import to U.S. ❑ Export from U.S. Pad ofentrylexit: Transportersignature (for exports only): - Date leaving U.S.: w17. TranspoderAcknowledgment ofReceiptofMaterials Transporter Printed7fyped Name Signature A Mouth Day Year O i �J/ 3 Tmnspoder2 Pdntedlfyped Name Signature Month Da ear h r18. 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 7i E5 / K:4 Facifily's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codas (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1'. 2. I 20. Designated Facility Owner or Operator: Codification of mceA of hazardous materials covered by the manifest except as noted in Ilam Ins Pdnted/fyped Name Slgnalure Month Day Year GG/; EPA Form 8700-22 (Rev. 3-05) previo editions are obsolete. DESiamATE® FAOII I O DESTINATION STATE (@F REQIMI D)