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Please print or type. Form designed for use on elite(12-pitch)typewriter.):I i p ObftC�1 WV-007 cp-'4r 1W .)0/10- ;>O 17 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 e, 0 r;;(N,l: 1. FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) .•a;.;1f��7jrt c�,r�:a :t 1•rntt of!ito.ktoll 4:IIrpp vtFv�? Of*t01%.CA`WV-,!0 3 Generator's Phone:' 6.Transporter 1 Company Name U.S.EPA ID Number ie au 41 avtfn:;:t.twu+.►nn�Mntre!��rlceiuc�s,till 1 A I-) . ,? •".r ;t "! r; r) 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number VP1 V Ali f pp t-Ji {till 4'+"'" Facility's Phone: i ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.0 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity WI.Nol. 13.Waste Codes 1-;O'IM 4,tit)L11Y1(': ifd'FA?W' f3f�t2lD�lY1:.l t(ZtiiCl,N.t?< 0 1' 0 Vnfit}C.f{4.Uf?!: c._1(1 x11.1)4 J001(=:At`llt)).B,t'(;11 • f w Z 2. LU U 3. 3 4. 14.Special Handling Instructions and Additional Information �.f'i .!S 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. Generator's eror's PrinledlTyped Name Signature Month Day Year -J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Dale leaving U.S.: K 17.Transporter Acknowledgment of Receipt of Materials w Transporter 1 Printed/Typed Name SignatureMonth ay Year p ;4 f_:r t.i4,i:.t.. QTransporter 2 PrintedlTyped Name Signature Month Day 7ear r 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue 1:1 Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U a LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z rn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 PrinledlTyped Name Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete1 llff W 1at11 aeaetlt thlr tiff 1,101elatol Is 5hippirtl; GENERATOR'S INITIAL COPY 9