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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 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number '.. WASTE MANIFEST I C ' ax w A mwv 012177786 JJ 5. General rr NNaa}me andMalting Address Generators SlteAddress (if different than mulling address) Generators 6. Tra0RI Comp Name 0.5. IPA 11) Number / Vz / e /�011sr1e/ez �1p ®FO®a5M '',.,.... 7. Transporter 2 Company Name U.S. EPA IO Number '.. 8 Deal nated FacililyN me and Site Address U.S. EPA ID Number A4 94% 7e 1114WI0 _J FrTZA Wits i�yJ �� 9 �3� �9 lYT� 0"6117 facility s Phone. '.. go, 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 WuVol. goo 17 Sif &I 0. 0120 19 3. 4. 14, Special HandlingInstructionsInstructionsns andAdditiog] IIntonation ,,(� 4 / p eJ2 510 t '] J sc 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydescribed above by the proper shipppiinngg name, and are classified, packaged, marked and labelediplacarded, and are in all respects in proper condition for boosted according to applicable International and national governmental regulations. if export shipment and I am the Primary Exporter, I codify that the contents of Ibis consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization stalemgnt 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. Generators2O rots P ledlfyped Signature' r ,/.J Month 2� Year ( y/Gj J 16. International Stilpfamas F- ❑ Import ta U. . F1 Export from U.S. Pod of enlrylexil: Z Transporter signature (for exports only): - Date leaving U.S.: W17. TranspoderAcknowledgmenl of Receipt of Materials Tru r�I PPrinntgalR ed Name gyp - l {1�� Signal F Month Day Year a Q 12 wil Transporter 2 PmdedfF ed Name Signature Month Day Year K r- 18. Discrepancy Ise. Discrepancy Indication Space [JDu ally [-1Type 11 Residue ❑ Partial Rejection LJ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J C7 r+a. Facllllyvs Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) a 1. ^ 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazer s materials covered by the manifest except as noted in Item fine Printedffyped Name Signature on y Y�ar EPA Form 0700-22 (Rev. 3-05) reVious ediffork are obsolete. DESIGNATED FACILIT` DESTINATION STATE (IF REQUIRED)