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1�181111N�I�NIIIIINIIN��IN ��IINI� Approved.OMB No.2050-0039 A Please print or type.(Form designed for use on elite(12-pitch)typewriter.) , Form P UNIFORM HAZARDOUS 1.Generator ID Number 2.Paget of 3.Emergency Response Phone 4.Manifest Tracking Number 1 WASTE MANIFEST �" 011392813 FLE 5.Generator's Name and Mailing Address Generators Site A dress(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phoney 9a 9b.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(if any)) No. Type Quantity WLNol. O _.. Z 2. W C7 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 EPAAcknowledgment 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 all quantity generator)is true. Ge erator_Offerors Printedrryped Name Si,nsture Month Day Year t 777 16.Internationa Shipments I- ❑Import to U.S. ❑Export from U.S. Port of e6 lexib z Trans orter signature for exports only): Date leaving U.S.: Ix 17.Transporter Acknowledgment of Receipt of Materials UJITransporter 1 PrintedfTyped Name Signature j ont I ay ear O .. a QTransporter 2 PrintedfFyped Name n ignature Montn 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_ V Facility's Phone: w ar9li 18c.Signature of Alternate Fty(or Generator) Month Day Year Q z U) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU G 1. 2. 3. 4. `t L 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 a` Signature Month Dayr Year r EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.