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Piea�e print or type, (Form designed for rise on elite 12 Itch typewriter )g ( . i? ) yp ) FormAparoFed OM No, 2050-0039 As' AUyiF4Rh� NAZ4RDC�US i , GuntD jusb q t ? 2 Pagaf of 3. Emelzt �lE�irieh�iM A, adfanifesl Tracking Number IF WASTE MANIFEST — 'r ��# } . r J IF IF 3 Generyg njf 77�tai rn ¢ (fza Y# t'3 p .W " Generator's' Site Address (t different than mailing address) ' 4 ' . - IF n I IF TE Myt AF , � n ? s !T wry IF,IF s: Generator's Phone. A AF— i[ 6 Transporla 'rgPaN� sa §3; a �.� - U.S. EP�iigtln]Ge _ F ? , —� IF IF - _ n 7. Transporter Company IName I A A U.S. EPA ID Number A . 8. Designilin F�clliM4 1 an"RROt' is U.S, EPA ID Number Facility's Phone ga• 9b. U S DOTDesc pt'io ti pnciuding Proper Strpp'ng Name, Hazard Class iD Number, 10. Containers it . Total 12, Unit HM and Packing Group (if any)) j R _t No. Type Quantity Wt.Nol, 13. ate Codes r .s,^. z . �. . . ewe FAA A V . -d , t— Wtyt 2 a IN 3 — — ---- AFT 4 IF 4. A A1� FAA i �yl As Special Handling Instructions and Additional Information EraF13TCT : R00 14r £ 51 : , * 'dCi i i1960411 -1 ,r"7 , I'! .= , '} r or FAA 15. GENi_RATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the.contents of this consignment are fully and accurately described above by the proper shipping name, aril are classified, packaged, marked and laboledlpiacatded, and are in all respects in proper condition for transport according to applicable international and national gove mental regulations. If export shipment and I am the Primary IF IExporter I certify{tial the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent I ce8iylhat the waste minimizaton statement identified in 40 CFR 282,27(x) (if I am a large quantity.generator) or (b) Of I ami nfal�quantity generator) is Irue, GeneraPorsJOfteroes Printed/Typed Name Signature Month Day A Year Yo J 16t Intemational Shipmehisr-—�Ek F- Import to U;S. ❑ Export from.U,S. Pori of entrylexit: Transporter signature onty): Dale leaving U.S:; 17. Transporter Acknowledgment of Receipt of Materials _ j LU Sj Trans ar;l Printedi� e am ; . ' Signature �� ^ ^— Month Day ; .Year . � f r ' l ' y`aF�r°> ,�3�, - o„"` ?'fs �..,v'su'r7;f+` `" c 7 5 •>A Transporter 2 PdriteolTyped Name ' Signature Modth Day wear E- 18. Discrepancy 18a, Discrepancy Indication Space l EQuantity ty 0 Type ❑ Residue ❑ Partial Rejection ❑ Ful( ReJection ✓ Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S- EPA ID Number JIF Facility's Phone: wt8r,. Signature of Alternate Facility (or Generator) Month Day Year Q 19. Hazardous Waste lReport Management Method Codes (!,a,, codes for hazardous waste treatment, disposal, and recycling systems) in a 17 2, 3. 4, 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials coveted by the manifest except as noted In Item 18a Printed/Typed Name J _ Signature Month Day ear IF AAA%(01 EPA Form 8700.22 (Rev, 3-05) Previciditions are obsolete. DESIGNATED FACILITY'S COPY ._ AS;