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Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pae 1 of 3.Emer ePo Res onse P}�onQ, 4.Manifest Trackln Number <br /> UNIFORM HAZARDOUS g <br /> p�' ..rt. l� 007314167 <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> f:iat'olr ?`r" p.kti`(,'.'Eil ( <br /> E'.'Fti r 7 !Fa Y .l.le <br /> i`'•if-ft'�(f�.t.�� l„'.fir i ��E f��,.:5� �.,� I'�i <br /> Generators Phone: albf ;''` 's`t')J:4 <br /> 6 Tran` orer 1 Come y Narp U.S.EPA ID Number <br /> `J <br /> 7.Transporter 2 Company Name U.S.EPA W Number <br /> tb } f@ <br /> B.Designated Facility Name and Site Address V L,f_;-0110 I-I-(f G.I ,y F){`,C` U.S.EPA ID Number J. <br /> .(•r..�1$_55';j ��! r��(�c t (iz I I"3\ �(.�ir ', <br /> t IIS -.,l.:rl#�1,� T {"�;'.3�.,if' <br /> -1H:.t i.�7"-f'•.it.� 4-6.1,".1 ""T <br /> - �1{i,S.'Y�ii��II,]P pYf_��:,9�'':�11 <br /> Facility's Phone: <br /> go, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(if any)) No. Type Quantity wt./Val. <br /> 13.Waste Codes <br /> HM tt 't )Y <br /> 1` t"ft,��`i`J (, rVrQ Y sel7eil'i00I3-"+ P-4 ASl�.- I A-1 �� �il�l <br /> O t1(•�} .�1) t'lIS(i1,w"i 4l# _fr Hr r_a.) 011.. <br /> 1 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 'f -Re' i`3'P' <br /> e`s.l r4lSi,a �1. �t".14� u4s,.a; ,['#s :F:° £( a (:1s3t ;.% tt` 1�,;r.e.f r y^c fill <br /> 15, GEN ERATOR'S1OFFER0R'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, <br /> marked and Iabeledfplacarded,and are in all respects in proper condition for transport according to applicable inlernalional and national governmental regulat€ons.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 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 small quantity generator)is true. <br /> Generators/Offerors PrintedfTyped Name Signature Month Day Year <br /> ,j 116.International Shipments <br /> ll�- ❑Import to U.S. ❑Export from U.S. Port of entryfexit: <br /> z Transporter signature(far exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tror}spoder 1 Prir tedrfyped Narpe Signature. Month Day Year <br /> Z Transporter 2 Printedrryped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity Type Residue 1 <br /> ❑ ❑ ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> 9 Facility's Phone: <br /> W 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> a <br /> to <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. C <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S HTIAL COPY <br />