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Tku qyVVs gdlq J Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page1of 3, DOWNY MuS Once Phone 4• Manifest hacking Number WASTE MANIFEST C'V3 Y 014789034 JJ 5, Generators Name and Mailing AAdressAAAje A 0V1 Rh& canisters Site Address (if different than mailing address) Generators Phone: Vb `X a t• 6, Transporter 1 Company Name U.S. EPA ID Number A[LIP &Le5rZUhdft1*4 7, Transporter 2 Company Name .S. EPAID umber B. Designated Facility Name and Site Address Cy�MdGR tf/Aae, A/ L U.S. EPA ID Number 3 P X5 1646 .S/e,14/AO`t leeM6 a C ,Fil 93R:99 �r��6yG1/ 7 Facilltys Phone: ?60 02212� go. 9b. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tobd 12. Unit 13. Was odes HM and Packing Group (If any)) /� No. Type /Quantity Wt.Nol. Odr K � 2!: 2. i r 3. 4, j 14. Special Handling Instruction andAdditional Information PRp FiGes ��Q�� l0 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, alit are classified, packaged, marked and labeled7piacarded, and are in all respects in properconi ition for Imneport according to applicable international and national governmental regulations, If export shipment and I am the Primary Exporter, I cergly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimizalion statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quanfity generator) is true. GeneratorslOfferoWrintdrry d Nam Signal Month yyDay iYje�/{ A@ =e 16. internationalLl Import bmimenis to U.S. ❑ ExP Cort from U.S. Port of entryrexi a-, Transporter signature (for exports only): Date leaving U.S.: w 17. TransporterAcknowledgment of Receipt of Materials t2 Tmnsporter 1 PdntedrFyped Name Signatu M/o9nth Day Year 0 / V Transporter Printedflyped Name I afore .Monti Da Year 18. Discrepancy 18a, Discrepancy Indication Space El Quality ❑ Type _ El Residue ❑ Padial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA IO Number .. J 'St Facililys Phone: Lie 18c. Signature efAitemate Facility tar Genemlor) •Month Day Year z 19. Hazardous Waste Report Management Method Codes (Is., codes for hazardous waste treatment, disposal;and recycling systems) ® ( /s�� 2 3. 4.1. t J � 20. Designated Facility Owner or Operator: Certificumn of receipt of hazardous materials covered by the manifest except as noted in Item 18a PdntedRyped Nam Signature o h Day Year . c am � Q EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. k DESEGNATED rAV ILIITY TO DESTONATION STATE (8F REQUIRED)