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k,urrn designed for use on elite(12 pitch/,ypewnterJ Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) ( Generator's Phone: V i 6. ransporter 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 ti .U.S.EPA ID Number Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10Containers HM and Packing Group(if any)) . 11.Total 12.Unit 13.Waste Codes 1. No. Type Quantity WtNol. O r W �r r x i LU 3. _; .� i:hi,u-iwl ir:c7c r xCin�'xtlAir t I 4. i 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. Generator's/Offerors Printed/Typed Name Signature Month ay- ear_ .j 16.International Shipments Z ❑Import to U.S. ❑Export from U.S Port of entry/exit: Transporter signature for exports onl : Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name � Signature ` Month Day Year CL Z Transporter Printed/Typed Name Signature _ Month Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number U Q a Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1 2. 3. 4. 1�� ility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a e Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. OESjGNATE0 FACILITY TO GENERATOR