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Please print or type. (Farm designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No, 2050-0039 UNIFORM HAZARDOUS 1. GenemtoriD NumberRespon z„ 2. P iof 3. Emergency se Phone 4, Manifest Tracking Number WASTE MANIFEST Ooo qo e :r' l u ' v " � `� . P L 012177663 JJ 5. GeneratofsjNa dMailingAddress 4 ' p;v . General �A�dress d fferentthan mailing address) G ner s Phone: •, f r E 03 9 Fr —f 6. Transporter l Compny Name /. .S. EPA ID Number 7. Transporter 2 CouTpany Name U:S. EPA ID Number e. Deslgnal 'd Facility Nam; and Itegddress ,,,2 � 0.S, EPA ID Number - F al P�ne. ga 9b. U.S. DOT Description (Includiny Proper Shipping Name, Hazard Class, ID Number, 10. Gontalnem 11. Total 12. Unit 13. Waste Codes HM nd Paclting Group (ifany)) No. Type Quantity Wt.Nol. � ✓J / W 2. 31 4. 14. Special Handling Instmgliops and ditional In ora lion - 2 -15. GENERATOWSIDFFEROR'S CERTIFICATION: I hereby declare that the contents ofthls consignment are fully and accurately described above by the proper shipping area, and are classified, packaged, marked and labeledlplacarded, and are in all respects in propercondillon for transport according to applicable Intemartionaland national governmental regulations. If export shipment and I am the Primary Exporter, I codify 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 CFR 262.27(a) (if I am a large quantity generator) or (b) (if i am a small quantity generator) is true. Goosedoe0fleroes Printed ypedNme r Signature Month Day Year --r 16, International Shipments l �. ❑ Import to U.S, ❑ Exportfrom U.S. Pod of entrylexit: Transporter signature (for exports only): Date leaving U.S.: 17. TranspomoAcknoMeQgment of Receipt of Materials -� Transpo 1 Pdn(edf(ypedf e 7 Signature „/ 7nth Day Year a C� � �I! r aTransporter 2 Prtuledlfyp . ame Sign re — Day Ver 18, Discrepancy Its. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 186, Alternate Facility (or Generator) - U.S. EPA ID Number J U LL Faditys Phone: w 180. 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) 1 , 1 2. 3. 4. r,1 JZ 20. Designated Facility Owner or Operator: Cedlficalion of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/typed Name - Signature Month Day Year 'RU 'fFc lldz�& La Z� EPA Form 5700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (OF REQUIRED)