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- Pleas€print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 T UNIFORM HAZARDOUS 1.Gen ID Number G 2Page lof 3Emergency Response Phone 14.Manifest Tacking Number WASTE MANIFEST 05-1 1-D 3 -��-Cp� /GGA 00 5 FLE 5.Generator's Na�men�d�Mailing A,.d//d ,J�� Generator's Site Address(ff different than mailing address) Ka{I) it rl 7ft% GL-G fny�7"f ,�rryes Generators Phone: 7gGt /�X Lgs 6.Transporter 1 Company Name � r Il JZ I V PAID Number Cbz-67JT7/" 7.Transporter 2 Company Name U.S.EPA ID Number MAY 0 2 2017 B.Designated Facility Name and Sit Atli EPA ID Number EG-,$ 7ifig ENVI'RONIMEWALF -. Z�L Jam. li?nc^R;r 4v!s F'EEtd1T/�iE2�9:.E9 z/� Facility's Phone: j,O „ C& n ZIS C4R OQO 2)� S� 9a, 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. Al DQcRA.W t�r�doi l✓tisk'. ��G`"%� �l�� .D1�1 Z�y f� ---_��._ Z 2. W 3. r i I 4. -14.Special Handling Instructions and Additional Information �. f &4 GJI�s fJnl �je �� 69601'A �rvwt P)4k1; i�7DID��So7�TTK . 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the Contents of this consgnment am 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 intemationat and national governmental regulations.If expod 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. I certify that the waste minimization statement identified In 40 CFR 262.27(a)(h i am a large quantity generator)or(b)(H 1 am a small quantity generator)is We. Generatoes/Offerors PrinledlTyped Name Signature _ on ay Year \-11111-14f091 .� If.In ematio hlpments i— ❑Import to U. . ❑Export from U.S. of enbylexit: z Transporter signature for exports only): Date leaving U.S.: Ir 17.Transporter Acknowledgment of Receipt of Materials ,y Transporter 1 PriniIyped Name Sign roMonth Day Year VA/jL QTransporter2 Printedfyped Name ignature Month Day Year od r } 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Padial Rejection ❑Full Relecfion Manifest Reference Number. h ,Bb.Altemate Facility(or Generator) U.S.EPA ID Number J U a r+- Facility's Phone: w IBC.Signature ofNtemate Facility(or Generator) Month Day Year Q Z r^ 9.Hazardous Waste Report Management Method Codes i.e.,codes for hazardous waste treatment,disposal,and re P 9 ( D cycling systems) ` .. 2. 3. 4. 20.Designated Facili er Operator.C:921 ion of receipt of hazardous materials Covered by the manifest except as noted in Item 18a Fri IypedN q Signature oN D,ay Ye EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DMIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)