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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 Numbef 2. Paage 1 of 3. Emergency Response Phone4.4. Manifest Tracking Number p� WASTE MANIFEST i�r'gC.y�® �:J ' ! /O 012177654 JJ 6� Ane ators Name and ling Address Generatofs Sfle Address (ifdifferent than mailing address) 2 Generators Phone: 6. Transporter i Company Name a U.S. EPA ID Number �ZO . l 7. ranspoder 2 Company Name U.S. EPA ID Number 8. esignamd Facili Norman SiteAddres U.S. EPA ID Number �t�2 ;R) CoR Facilityzs Phone: 15 c �59c' " %`711 1AIK ` 7 '.. ga, 9b. U.S. OOT Description (including Proper Shipping Name, Hazard Class, l0 Number, 10. Confainers .11. Total 12. Unff 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wtrvol. 3. tl 41 14:SpecialgHandling Ins,�ons and Additional infer ation (ciLZd1�`��C,,. 15. GENERATOR'S/OFFERORS CERTIFICATION: I hereby declare thatthe 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 propercendition for transport according to applicable international and national governments[ regulations, Ifexpod shipment and l am the Primary '.. Exporter, Icerlify 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 CFR26227(a) (if I am a large quantity generator or @) ('rfl am a small quantity generator) is true. Genera,offe rs Prkntedrryped Nab Month Day Year " M �+ C . 4 16. International Shkpments r ❑ Import .S. ❑ Export from U.S. Podofentrylexii: Transporter signature (far exports only): Date leaving U.S.: M 17. TranspoderAcknowied mant of RecelptofMarsden F Tra spoiler 1 PrintedRype a S'�o lure - Month Day Year O 4Transpoder2 Pitntodfrype J Nome Signature Month Day Year f- .N 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type F-1 Residue El Partial Rejection L1 Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) A.S. EPA IO Number J U uu Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Month 'Day Year C z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® i . 2. 3. 4. till 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a `II(. Printedrryped Name Signature Month Day Year t� � ul Ile EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY/ TO DESTINATION STATE (IF REQUIRED)