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Please print or e. Form designed for use on elite 12 itch typewriter.).;i 3 -'(1`,}'itf i'IFi f tr!>;' (',k V;)IJ r 10, 1O,':O° p YP ( 9 ( P ) Form Approved.OMB No.2050-0039 I INIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking,Number WASTE MANIFEST f c FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number • ....i 1.S�i.. Ftk•.1: �If;Hra1!;tR ,, ,�j�.�; t, 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Ai?4)15941.)4 3 10 Facility's Phone: ; i 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1 � tiff t'.115 i it ';!+)��f�i 1!`�itil),i'/:',i� ,Ii'!C))2L;/1Nfr , Frim►•' 14"' + Q011011AI.)vf.l2owIl1F LioIAt vu lip"f-fy )yfvVIC)C) Z 2. w c9 3. 44 4. p , 14.Special Handling Instructions and Additional Iniorm lion t t 1' ill°A�r:�C M 15. GENERATOR'SIOFFEROR'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 EPAAcknowledgment of Consent. 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. Generators/Offerors Printed/Typed Name signature Month Day ear J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year a iz1r:41'out.RJ-"Ft z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q u<- Facility's Phone: ' C3 18c.Signature ofAiternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatment,disposal,and recycling systems) 0 1. 2 T 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 Name Signature Month Day Year EPA Form 8700-22(Rey.3-05) Previous editions are obsolete.. GENERATOR'S INITIAL COPY 1ct rain peraeitts for and will igiettt 1t,�kasto[ht!�ertelat+u is hi 11,