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3�L 6li bMilJ � - Illlli l ll i l l l llll 1�11II 0 0 8 5 6 1 9 6 2 S K S Please print or type. 2 3 si Form Approved.GMB No.2050-0039 UNIFORM HAZARDOUS 1-Generator ID Number L;HLWIthW S1:ienJt, 2.Pae 1 of i_l aw elons ffh�a� 4.ManhatTracking Number WASTE MANIFEST 1008561962 V K5 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) U' Keiily # clb-i 460 Lher'1]kee Ln . 1j—L.""1deta06 LUD 1 LH 'JbC441--IQWWW Generator's Phone: �� �,r0�r,�gREVINn",Y�i i LP16 LNL U.S-EPA ID Number I x}Ci weAdbl i 03 7.Transpo er 2 Company Name U.S.EPA tti Number IYA3a3931�� 8.Designated Facility Hame and Site Address L;LtH€►i HHHHUHS BIW J(JbE -S.EPA ID Number iWci t1EHHYL6�iR HURV ;aRN J LJ6E , Lf 4 'it)16.5 40 d-4 41—IdtJ6c L:HL WaV4,J4,�1 td Facility's Phone: ga. 91b.U.S.DOT Descripfion{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.luol. '11gi1E, Fi1 >Mr NUN—HUK5 HH1MU6 Ri i t., 6l.L IV, IN- F' }.6= p i=.i HL DUb i H U M!-LUH1NiNIJ WAb I E Ile), 2, LU s7 3 i 4. 14.Special Handling Instructions and Additional Information i yD;b.! UH 1 E44C4 L66'. ds 0 LA-15(0 e4it retairleo Dy generator conters agency autharit on initial transporter to a= or substitute auditionai trans Qrters ongenerator' s behait. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignment 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 intemaltonal and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the teens of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a Small quantity generator)is true. GeneratorVOfferar�Pnntedf yped Name Signature M tth Day Year .\rte x- 16international Shipments F El Import to U.S. ❑Export from U.S. P . on of entrylexit: ? Transporter signature(for exports only) Date leaving U.S.: Ce 17.Transporter Acknowledgment of Receipt of Materials 12 Tran er 1 PrintedP ame Signature Day Year a Z Trani por{er2 'ntedlTyp ame Siignature Month Day Year Yc�► IG Z� 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial R ❑FJ Reyeetion Manifest Reference Number: 18b-Altemate Facility(or Generator) U.S.EPA 1D Number V Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i-e.,codes for hazardous waste treat t,disposal,and recycling systems) C 1. rr 2. 3. 4. t�l 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manffest except as noted in Item 18a Pdntedffyped Name Signature Month Day Year rr va CEO IL&tsh ,� d EPA Farm 8700-22 PeYl 117] Previous editions are obsolete. . . DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM