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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. Ge erator lD Number 2. Pa eiOf 3®. Emergency Response Phone 4. Manifest Tracking Number g �/ WASTE MANIFEST ® ��® ® ®® ® � 784 J J K 5, Generator's Name and Mailing Address Generatots Site Address (if different than mailing address) Generatots Phone: 6. Transporter l Company Name T. Transporter2 Company Name U,S. EPAID Number 8. Designated adlity Namea dSlte Addfs U.S. EPA ID Number �s� ® 04d i& 41 1, A&� � Z� & < / ® j Facility's Phone: Sq { " 9a. 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 1 O. Containers 11. Total 12. Unit 13. Waste Codes HM and Packing Group (Ifany)) No. Type Quantity Wt.N01. (z,,f 11"wellknIA02 . N214 go/ 2 3. 41 14. Special Handling Instructions and Additionallnformation ./� /� �D ,r/ �� ee OP99 90 06, 10 15.. ,GENERATOR'S[OFFEROWS 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 Iabeledlplacarded, and are in all respects In proper condition for transport according to applicable international and naltonal governmental regulations. If expod shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the agached EPAAcknowledgmentof Consent. I certify that the waste minimization statement idenfified In 40 CFR 262.27(a) If I am a large quantity generator) or (b) (if I am a small quantity gene atod is true. Generator's10 rots pe a Signet Month Day Year 6 f� J . n emafonal Shipments ` r. mpod to U.S. ❑ Expadfrom U.S, Port ofentrylexit: � Transpodersignature (for exports only): Dale leaving ILS.: w 17. TransporterAcknowiedgment of ReceiptofMaledals � Transport Printedffyped Name /� g �s' Signet Month Day Year h ® Si nature Month Day Year Q Transpo erg Pdntedlfyped Name 9 h .p 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection . Manifest Reference Number: 181h. Alternate Factity (or Generator) US. EPA ID Number J U Facilit> s Phone; � 18c. Signature ofNtemale Facility (or Generator) Month Day Year Q 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) ® 1 2 3, 4. I. 20. DesignatedFacility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item ins I Printedffyp dName Signature - Mon �Day Yes EPA Forma 00-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FAC060TYTO DESTINATION STATE (OF REQUIRED)