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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HA2AROOUS 1,Generator ID Number 2.Pay Emergency Response Phone 4.Manifest Tracking Number CAIF LE CAI-000433477 t_e,�M__4.I.H 17��1 WASTE MANIFEST 5,Generators Name and Mailing Address Generators Site Address(if different than mailing address) ;r 1 3 1+. J.—IJ-1-0i r' ..TrrC.C', '-]:J.7f.F—i71Q1;71k'� Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter2 Company Name U.S.EPA ID Number !_1_'=i?:.i H4,1!R 1Rc 17MVIt7;Itq{MENTMI.. 91 TNN! 8.Designated Facility Name and Site Address 171—FAN stA^EtCIR.. ._�eGP1 Tmt;- U.S.EPA ID Number - _�- 10-2t RFRRYF P F#11AP %x919-441—A.'1 .tTU !:c`3_r.•:1_;,'?s Facility's Phone: 9a 96,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(rf any)) y No. Type Quantity Wt./V0.hJC{ }arAZ71RTlC1lI i InlASTFt `<f1•l._IT} )�M 1 /J� C' '• FO a• -T { i i i 4. 14.Special Handling Instructions and Additional Information c T .,Y7 f,..,c..z�.t, _n 107 C� f s if,Cgjr"`/a3P0 0- 'H `3 Ff. iTe v yen r�3� c � _ encZ hO5 Y art 15 `GENERATOR'SlOFFEROR'S CE TIFICATION:I hereby declare that the contents ofthis consignment are fully and accurately described a ve by the proper shipping name,and are classified,packaged. marked and Iabeledlplacarded,and are in all respects in properoondition for transport according to applicable international and national governmental regula is.If export shipmentand I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknovdedgment of Consent. I certify that the waste minimization statement identified in 40 Cl 262.27(a)(if I am a large quantity generator)or a small quantity Roe r true. G era torslurorors Prince yped Name rgn on ay ear EZ 16.International Shipments H ❑Import to U.S. Ll Export fromL.S. Port of entry d: Transporter signature for exports only): Date le U.S: W 17.Transporter Acknowledgment of Receipt of Materials : Trans rte 1 dntedRypetl arae ISignature Month Day Year a z Transpo)jAj Frintedcry0bd Name Sqnature I FIli luay year.;,-. 18.Discrepancy 18a.Discrepancy Indication Space ❑Quantity Type 1 ❑T ❑Residue ❑Panial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U a tL Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year a z LU19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. / 2. 3. 4. 20.Designated Facility 2yeror bperator Certification otreceiptol firdous materials covered b e manrfest except 9pted in Ice 1 ' PrintedlTy Name Signature M Oay Year EPA Form 8700-22(Rev,3-051 Previous editions are o solete. DESIG ED FA TO DESTINATION STATE(IF REQUIRED) -7'7