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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 1. Generator ID Number . 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number UNIFORM HAZARDOUS g'°<'-- <ra .y _ ri3z, a 012177766 JJK WASTE MANIFEST fJ�,O ppp yy sl y� PFF �- _� v^ rr c 5. Generators Name and Mail' gAddress' Generators Site Address (If different than mailing address) la � R � paV 7b E715, I.&W695. 5r' I t aUa IZ-'rveat 95'2e6 Generators Phone: "a,eJ 2Y a O 6, Transporter 1 Company Name U.S. EPA ID Number '.. P &11L I W am ' sv U Md s iLr © t2 f? 7. Transporter 2 Company Name US. EPA ID Number ',.. B. Designated Facility Name and Site Address Ygt4 lbtoL GVI'1°S(d� M div fj 6LNd' I We U.S. EPA ID Number '.. 35�Sf ok 'o r9- 6V4I17 Karr ri� r? asar9N, c0? 23 3 (f Facility's Phone: 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 WLNol, '.. ® 1 / v IQ }k -., r , r;r r- f /�rr.�i % t a E s J— . w_ 41 fir OW X:2 3. - p 4. P 14. Special Handling instructions and Additional Information _ 15. GENERATOWSlOFFEROR'S CERTIFICATION: I hereby declare that he contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, marked and labeledlplacarded, and are in all respects In proper condition for transport according to applicable International and nallonal governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to (he terms of the attached EPAAclmowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR262.27(a) fff I am a large quantity generator) or (b) (ifI am a small quantity generator) Is true. Ge ra�oels-l;OffeJrjg/813flrteedd'/Txped Name Sign re Month Day yYear -r 16. International Shipments '.. !- ' Import to U.S. ❑ Exportfrom U.S. Pod of entry/axil: Transporter signature (fer exports only): Date leaving U.S.: DO 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdnted7ryped Na�nmte Signature Month Day Year MTransporter2 Printedlfyped Name Signature Month Day Year 18, Discrepancy '.. 18a. Discrepancy Indication Space ❑ Quantity Ll Type L1 Residue ❑ Partal Rejection ❑ Full Rejection Manifest Reference Number: 18h.Alternate Facility (or Generator) U.S. EPA ID Number - U Facility's Phone: w 18c. Signature of Alternate Fadlily (or Generator) Monih Day Year 10. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1. 2. 3. 4. . 1 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year r YA�) I N101 4 EPA Form 8700-22 (Rev.3-05) Previous editions are obsolete. DEStONATED FAC&L65fY1 TO DESTINATION STATE (10 REQUIRED)