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Il l 11 l l 11 11 11 l lllil 11 l 11 11 1111 l 11 i lii 0 0 8 1 4 3 2 6 3 S K S Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 008143263 5 KS 5.Generator's Name and Mailing Address Generators Site Address(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 Phone: ga 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 Wt.Nol. / 1. O - L 2 1 W 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ari classified,packagec, 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. certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(114m a small quantity generator)is true. G er or's/Offeror's Prin ped Name Signature Month Day Year 16.Inter tional ipments F- ❑Import to U.S. ❑Expo,-t from U.S. P of try/exit: _ _ - ? Transporters t (for exports only): D aving U.S.: CC 17.Transporter Acknowledgment of Receipt of Materials Tr iter 1 Pnnd T Name Signature AjMonth Day Year Ito it � =�I Z Transporter 2 P nted/Typed Name Signature Month Dav Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue Rejection lection ❑Partial Re Full Re' Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 0Fn- 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 intera e - S' nature � nth Day �!aaI EPA orm 00-22 (Rek.12-17) Previous edition solete. DESIGNA :D ACIUTY TO EPA's t:-MANIFEST SYSTEM