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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 e e WASTE MANIFEST A04022 r � C 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) pan * tg ULC Fp. w M Gone toes Phone: 6. Transporter 1 Company Name U .S . EPA ID Number ' , V 7, Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U .S. EPA ID Number 6133 r t Facility's Phone: 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 WtNoi. o AAV) CV J tRw w #x BM P I I 4. 14 . Special Handling instructions and Additional Information PTIO € t" v " ;'" 4 15 GENERATOR'SfOFFEROR'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 labeledlp!acarded, 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 haat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste mWmization statement identified In 40 CFR 262:27(a) (if I am a large quantity generator) or (b) (if t am a small quantity generator) is true. GeneratorslOfferor's Pnniedffyped Name Sgriature Month ay Year J 16, International Shipments Z 1:1Import to U.S. ElExport from U .S. Port of entrylex4, Transporter signature for exports only): Date leave U .S. : 17. TransporterAckno%ledgment of Recer'pt of hialerw's LLJ Transporter I Printed/Typed Name signature Month ay ear t f Z Transporter 2 Printed/Typed Name Signature Month Uay Ye21°' d t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Ouan6 ty ❑ Type El Residue El Partial Rejection ❑ FuR Rejector. Manifest Reference Number: 18b. Altemate Facility (or Generator) U .S. EPA ID Number _J V d �+ Facia s Phone: 18c Signature of Allemate Facility (or Generator) Month Day Year d Z 19. Hazardous Waste Report Management Method Cordes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1 . 2. 3. 4 . = //J 20. Designated Facility G4-ner or Operator: Certification of rq&pipf hazardous materials covered by the man fest except as noted in Item 18a Printedrryped Namev, j ' Signature ' Month Day Year Ilvt . • r ' C 1 t d t , ; ,� EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. —. _ DESIGNATED FACILITY TO GENERATOR