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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 • Generator ID Number 2 Page 1 of 3 EmergAeney Response Phone 4. Manifest Tracking Number pyx aG JJK WASTE MANIFEST -' t - " r '.r ' 5 Genratoes NaRe and Mailing Address t t orrwb r .f Generator's Site Address (if different than mailing address) ILI Generator's Phone: - 6 Transporter 1 Company Name U .S. EPA ID Number 7, Transporter 2 Company Name U .S. EPA ID Number 8. Desi n 0d aiiilik a ndl9P Address U.S. EPA ID Number Facility's Phone. - 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12, Unit HM and Packing Group (if any)) No. Type Quantity Wt.N01, 13. Waste Codes x> z 2. , P f tLIr P /0 r ;: f 14,,Special Handling Instructions and Additional Information 15. GENERATOR'SlOFFEROR'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippinginame, and are classified, packaged, marked and Iabeledlpiacarded, 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 certify that the contents of this consignment conform t0 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. [Ga�ne?ra,,,1,,oi`s/Offero?s Printed/Typed Name J Signature Month Day Year 16, International Shipments ❑ Import to U.S. LJ Export from U .S. Part of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAclmowledgment of Receipt of Materials lr� Transporter 1 Printedrryped Name E _ Signature Month Day Year O P � r- ZTransporter 2 PfinitedlTyped Name Signature A A Month D'ay ` Ye r 18, Discrepancy 18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial ,MIM ❑ Full Rejection COVED. t�NV-M AND STORM FOR FACWTV UNDO CV WASTZ WAS tBRlf6Tf r i C. OpMA 14M 11111:11IRSURN law COKRtD TOGHf 18b. Alternate Facility (or Generator) l�l111100 d., OT r t gy Ttd DEPAR 11 ICA1112 :D NMI - �tACVt AI, FRUCECTl4N AGENCY Pt ACCORDANtl A t e Q W� rViRQNhtSNt Y ACT OF t976 TOGA OF TW NFCO$KRY WoUKLU GUN:�4tYATitoN CROSBY WAMANb w STB w s � "NANDtJW W Facility's Phone: tg RRCWLk ALL W 18c. Signature of Alternate Faculty (or Generator) 1190,41M TO ACCFJzT Month Day Year Z � r`CtStUj��Y 19. Hazardous Waste Report Management Method Codes (Le', codes for hazardous waste treatment, disposal, and recycling systems) LU 1 1 2P 3, ¢ 20. Designated Facility Owner or Operator: Certification o,�receipt)of4hazard" materials covered by the manifest except as noted in Item 18a I Printed/Typed NamF 7rt" j 4 r f Signature w ,, Month Day Year p , EPA Form 8700-22{Rev. 1V7) Previous editions are obsolete; DESIGNATED FACILITYTO GENERATOR u t