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Please print or type. (Form designed for use on elite (12-pitch) typewriter) l Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Pa[ 1 of 3. Emergency Response Phone 4, Manifest Tracking Number p WASTE MANIFEST 009400319 �JJ K 5. Ge emtor Name and Ma91n of rens ` - Generators Sit Address (if different than mailing address) 70 cr Generators Phone: ® e9b A 1 6. Transporter 1 Company Name U.S. EPA ID Number d 6 . . Transpoder2 Company Name U,S. EPA ID Ndmiber 8. Designated Facility Name and SiteAddmss dNeMICAL z. / 0t 2gyBr�P eMekir 7 c, U,S. EPA ID Number '.. s" � 2�! OBD fib' L; ;A V Facilltys Phone:JSr r3e x get 9b. U.S. DOT Desorption (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 Ouaptity Wt.Nol. lV0A) ( 14 J0 W45re, 506AD z 2. g 3. 1 4. 3P3P4 14. Speclai Handlin nshuctions andAddiflonal information - 15. GENERATOR'S/OFFEROR'SCERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately descrlbed above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects In proper condition for bansport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, Iunity (hat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I sedgy that the waste minimization statement idemilled in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. G lotsto emrsyrinted/rype Name Signet Month Day Year �J 16. international Shipments r— El Import to U.S. ❑ Export from US, Part ofentrylexit z Transporter signature (for exports only): Date leaving U.S.: w 17. TmnsporterAcknovredgment of Receipt of Materials _ Transporter l Printedfryped Name Signature Month Day Year �jFk 10911t Vot m Transpoder2 Priatedrryped Name ig lure Month Day Year tr F 18. Discrepancy 18a. Discrepancy indication Space ❑ quantity ❑ Type ❑ Residue ❑ PaAlal Rejection ❑ Full Rejection Manliest Reference Number: h 18b. Alternate Facility (of Generator) U.S. EPA ID Number I J 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) 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous matedals covered by the manifest except as noted in Item l8a Prnted(ryped Name Signature Month DayYL EPA Form 8700-22 (Rev. 3-MrPrevlous editions are obsolete. DESIGNATED FACkRIN TO DESTINATION STATE (GF REQUIRE®)