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a PJease`print or type.(Form designed for use on elite(127pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mani st TrabingNu b 1503 WASTE MANIFEST a;trs,s S;"�>rr.,,t ; t. r1�I a s' �.� �� 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address)' Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: el(ftt f:t t �304- OV11 i, m)1 0000 ga 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 Wt.N01. o w L'Z I. o t rri? a_. - >,, e 3. 4. } 14.Special Handling Instructions and Additional information 11 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all,respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certifythat 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. Generat/ors/Offero�rfs Printed/,,Typed NameA igna ure ton a er 16.International Shipments h ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: W -17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Sigo Mon Day Year aTransporter 2 Printed/Typed Name f `Signature Month Day Year. y aF- 18.Discrepancy 18a.Discrepancy Indication Space ElQuantity ❑Typej j ❑Residue El Partial Rejection El Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V u- Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Repoft hlanagernent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY