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Please print or type.(Form designed for use on elite(12-pitchy typewriter.) Form Approved,DMB No,205MO39 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone FManil Tracking Number �[ WASTE MANIFE5T _ 017468610 JJ K 5.Generalors Name and Mailing Address Generators Site Address(9 different than mailing address) Generators Phone' 6 Transporter 1 Company Name U.S.EPA ID Number •4'1`+ter"•'�i1 01L �. . J'J--L, _ . ., 7.Transporter 2 Company Name U.S.EPA ID Number 8-Designated Facility Name and Sile Address U-S.EPA ID Number J73.-'O :JGY VEHNt; 1`,lC Facilirls Phone: ?'+--':ri 9a. 91 U.S.DOT Description linduding Proper Shipping Name,Hazard Class.ID Number, 1C.Containers 11.Total 12.Unit 13 Waste Codes HM and Paciung Group(If any)) N4 Type Quantity Wt Not. ltJ0N-RC RA HAZAi'00 US WASF L' L r- T. �1:4.4 iLFAM-�!:1 i'._ .... t- 2 Uj . i i 3. j I I 4 F E � 14.Special Handling Instructions and Additional Information ENIER,GENCY CC ti7A T CHE'.."FcC _-S' 424 333C' '4 CE_-Zr'i!,d .L ;'3# E.- .!.7. "s' '. 'IF"L # E 1 6G16'3 i LATHE SHAVIEJGSPriUu J 1[J>�3u k hf F R' PF'l:f k PP`:. [..`.,�'JIPPviE'I i ?)C)?—�J f V 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fusty and accurately described above by the proper shipping name,and are classified,packaged, marked and abcledlplacarded,and are In all respects in proper condiion for transport according to applicable Irriernational and nat'onal governmental regulations.IFexport shiprnent and I am the Primary Exporler.I certify that the contents of this consigi eM conform to the terms of the attached EPAAckricrMedgmont of Consent. I certify that the waste mirimilatlOn statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) d I am a Viali quantitygenerator)is true. tarsl0ifemr •ntecJT Name n re M" Day Year ri 16.International Shiprnents F ❑impart to U.S. ❑F�po t from U.S. Port of entryiwdt: ? Transporter signature(for exports only): Dale leaving U.S.: 17•Transporter of Receipt Materials Transporter I P Name SignatureMorrth Day Year ams"kz ID Z Transporter 2 PrintedlTyped Norm Signature Month Day Year a F- 18.Disarapeaoy 18a.Discrepancy Indication Space ❑ Quantify ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 181 Alternate Facility(or Generator) U.S.EPA ID Number J U Facillys Phone: Lu Ik.Signature of Akerri Facility(or Generator) Month Day Year a a y19.1 Waste Report Management Method Codes(i,e-,codes for hazardous waste treatmerrt,disposal,and recycling systems) 1. 2. 3. 4. 2U.Designated aril' r or 0pera .Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 M PnntedlTyped Nam Signature Month Day Year C� EPA Form 8706-22(Rev.3-65)Previous editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)