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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS Res�• 1.Generator ID Number 2 Page 1 of 3.EnteregG ogse P�h=�aee 4 Manifest Tracking Number r ;>3Yllj ,y T .t F D G p WASTE MANIFEST � ;'4 la 5.Generators Name and Mailing AddressGenerators SlteAddress(if different than mailing address) 991i}.�.) ''"y'[,�w.gN4J "3; a� q'} y5�gir(:i ,IMUS 3;aJ„6 41ir' p.4,:'iia^ }.:. Generators Phone::; !yZx:7. R� S`.i:+�:.iLI. `�a..}y YV'1 `y,Ii& .? 6.Transporter l Company Name qqS U.S.EPA ID Number 1 4M T 111 1 9' ' �:f'� `,•flV f 4!y'}+;i fro rt'#�, 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number '"ALIFI)INIA Off TKNNSY-INK, f. 0 1i tg t. t aZ mor L^fy. 'Y'v t y'1 s yart a .. Facility's Phone: JU T'a;��. cx.w,s�..:,T f.aly -i1 .. ., . ,.'.3.MID }�..1;61 gin 91b.U.S.DOT Description(including ProperShiplaieg area,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) . t`r No. Type .Quantity t.Nol.W 13.Waste Codes (USED OR. -r [i Z 2 out 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,arid are classified,packaged, marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable inter national 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)(N I am a large quantity generator)or(b)(if I am a small quantity)ene ator)is man Generator'sl0frames Printed/Typed,Name - Signature s, Month Day Year in, 16.International Shipments- f— L1 import to U.S. ❑Export from U.S: Pon of entry/exit: = Transporter signature(for exports only): ,Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transpoder l Printed(Typed Name Signature Month -Day Year O , . 5, } t;1 Q Transporter 2 PrintedlTyped Name k '— - Signature j Month Day Year r, f t18.Discrepancy. 18a,Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection El Full Refection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number - U I Facility's Phone: C3 - 18c.Signature ofAternate Facility(or Generator) Month Day Year 6 Z ILD 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) L # 2. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Rnntedlryped Name j i Signature ', Month Day Year EPA Form8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL CORY