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Please print or type. (Form designed for use on elite ( 12- pitch) typewrite(.) Form Approved. OMB No. 2050-0039 TUNIFORM HAZARDOUS 1 . Generator ID Number t i .- C 2. ,P{age 1 of 3 . Emergency Response Phone . Manifest Tracking Number ASTE MANIFEST � n �� o "1 �� l— [xD ( I ' F L E .� enerator's Name and Mailing Address y enerators Sue Address (If ddferent than mailing address) /\ ` �) je(t #N �_ F . S` �''� t 1J > c �3 �: �5 �:GNT� :✓ t lJ ` L G C� Generalvr's Phone, 1 f C• 1. Com'' , 3 T� '� SL4 5 Transp-Arir 1 Com plany Jame U .S EPA ID Number Transporter 2 Company Name U.S . EPA ID Number 8 Des gnaied Faciii y Name and Site Address �,� } `� t6 ; � I l 4 b LV' L U S EPA ID Number C-EO H0i 160 1; b CO Facility's Phone: 7 GJ 64) CO 98. 9b US DOT Description (including Proper Shipping Name, Hazard Class, 16%umber, 10 Containers 11 Total 12 Unit 13 Waste Codes HM and Packing Group (if any)) No Type Quantity WLA/01 1` 1.1pA .'>�``� t A '2 .31 ,` t t: t c t:� .a ; `T E Sl1 \. 1 Cru r • U S frS L r� ( L 1 C A Q rn 11••iu i1'J - LCAD 01 715 � w Z - - - c� „ 4 - - I— - 14. Special HandlinInstructions and Additional Informatior - I r CN 169 '* 15 GENERATOR'SIOFFEROR'S CERTIFICATION: r hereby declare that lite contents of the consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. It export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the, terms of the attached EPAAeknoWedgment of Consent I certify that the waste minimization statement identified in ori: CFR 262.27(a) (if I am a large quantity generator) or (b) (it t am a small quantity generator) is true General s(Ol em a Inted y p nme gna ure on ay ear go L C-, '' a • ' dray �� • �3vs ;r/ NL s, . } -� to Intemmrceal Ship ants f�1 Import to U S !_1 Export from U S Port of on lexit _ transporter signature far exports only)'- leaving il. `1 17. Transporter Acknowledgment of Receipt of Materials Transporter + rinledrTyped Name 51gnalum f Month ay Year Transporter 2 Prin ediTyped Name ignetum Month Day Year 18. Discrepancy !� 18a Discrepancy Indication Space L j Quantity O T pe y � Residue ❑ Partial Rejection ❑ Full Rejection _ Manifest Reference Number: 18b Alternate Facirty (or Generator) US EPA ID Number _J V Q LL' Factll 's ?Ilene' 18c Sgnalure of 4N�mate Facility (nr Geneiatnr) Month Day Year Q Z 19 Hazardous Waste Report Management Method Codes 0 (4 . codes for hazardous waste treatment, disposal, and recycling systems) • 1 ' J � "1 � Z. 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 dame Signature Month Day Year EPA Form 8700-22 (Rev 105) Previous editions are obsolete. DESIGW Gig FACILITY '170 DESTINATION STATE (IF REQUIRED)