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Please print of type. Form Approved OMB No. 2050-0039 <br /> �NIFORPh HAZRR60US 1 , Gen t IDN er 2 P p 1 of 3 E yency Resp Phane 4 r1 f s, - 9 Number11 <br /> WASfE PJIANfEESI ,_ :� s Ir JJ <br /> 5. Generators Nane and Malllnir AUdres „ r , r - Gereratms Site Address (if different than resulting addles ) , <br /> Generators Phone: It <br /> ' <br /> — — . <br /> 6. Transporter i Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> B. Designated Facility Care and Site Address r U.S. EPA 10 Number <br /> Facilty PI e <br /> 9a 91c. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . later 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WLN01. <br /> Z 2. <br /> LDLD <br /> 3. <br /> 4. <br /> p ling Instructions and AdditonalInformation <br /> ,_ t = <br /> 14 5 0 el Hende- <br /> 1 14 Ir <br /> t <br /> �. ,. <br /> L <br /> 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, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for Iransporl according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> Expender, I caddy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cedily 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 We. <br /> GeneralotsfOlgatirs PrintedlFyped Name Signature Month Day Year <br /> r 1 � <br /> 16 International Ship nts <br /> i— ❑ Import to U.S. ❑ Export from U.S Part of entry/exit: <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. Transporter Acknowledgment of Receipt of Materials <br /> 1- Transporters Pnnted(ryped Name Signature Month Day Year <br /> a <br /> y Transporter 2 Printedlryped Name ; Signature Month- Day Year <br /> F <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> h 186. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> u< Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> ® 1 2. 3. 4. <br /> 20, Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />