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Please print or type.(Form designed for use on elite(12-pitch)typewriter.)' ) ! 'OFr!`��t 191 'i 1' W)%' C. 'f1VW 101 101, O t 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 I. O 0 t! :; i t t FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) GeneratorsPhone: ,'. ; } ''_;':t ransporter ompany Name U.S.EPA ID Number +it=rfl EI,Silint c l ttvirr3f;lFtF+frial!ieevitu�s,lar,. 2. 2 i 5 U 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA 10 Number .,fl f)•tiifl:rt,tient ?rr•,i1I )rSt> CA 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)) 13.Waste Codes No. Type Quantity WtNol. ,. ird1266.WAS f.CORR Ot -N, ii,,iIII .RM1 .IIiOH46AMN`, o {snE7FttmW?')JI;t7ui{►t�-,cn►t�y�;)t)A43Fvt►Ft;!twill 7i.1,fz,a,; Z 2. W ra 3. 4. 14.Special Handling Instructions and Additional Information 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 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. Generators/Offerors Printed/Typed Name Signature Month Day ear -i 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.TranspoderAcknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year CO Transporter 2 PrintedlTyped Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residuej ❑ ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q �+- Facilit's Phone: ' w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) L 1. 2. 3. 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 87.00-22(Rev.3-05) Previous editions are obsolete.. GENERATOR'S INITIAL COPY t7nnfRttatr pvrFFnss tpf:yFfrl will 19tePt IhO W45110 IhP ttNrtNFatra is khiuFtfnc.