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i <br /> Pease print or type. <br /> UNIFORM HAZARDOUS 1•Ganerat0 Ip Number Form Approved.OMB No.2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST , ! r ?d t� G B F <br /> - '� <br /> 5.Generator's Name and Mailing Address —` Generatods Site Address(if differe35?nt than mailing address) <br /> f�v- 95%- fi�S <br /> GAeratoN Frnone: <br /> 6.Transporter 1 Company Name <br /> U-S.EPA ID NumberAA <br /> 7.Transporter2 Company Name � � �1�- �' �.4 t�^�1- 1,610412 <br /> WbYEMv +f rU.S.EPA fCt Nuin <br /> 8.Designated Facility Name and Site Address <br /> [ 0.L.ttiY U.S.EPA ID Number <br /> IfJ� id S CF MATTY <br /> Facility's Phone: ` IWAT l , M W003 W 33001000 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> yM and Packing Group(if anypJ 11.Total 12.Unit 13.Waste Codes <br /> 1 No, Type Quantity Wt.Noi. <br /> CK <br /> Z 2.LU <br /> . <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> 1PR0R1 F )0T RG W7 9 2-557)M <br /> ? Rte#LsT T f i WAR M)PET. PPE#?M <br /> k15GE—NERATOR',,S1,O, FFEROR'8I.6a CERTIFICATION: i hereby declare that the contents ofthis consignment are fufiy and accurately described above by the proper shipping name,and are classified,packaged, <br /> rked and Iabedlplacarded,and are in all respects in proper condition for transport according to applicable intematenal and na{tonal governmental regulations.If export shipment and 1 am the Primary <br /> porter,I certfy 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}(if i am a large quantity generator)or(b)(ill am a small quantity generator)is true. <br /> Generator'sl0fferor's Printed Name Signature <br /> Month Day Year <br /> 16.fntemat onal Shipments <br /> ❑Import to U.S. ❑Export from U.S, I Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.:' <br /> lou 17.Transporter Acknowledgment of Receipt of Materials x <br /> I Transporter 1 Printoollyped Name Signa <br /> Monthflay Year <br /> Z Transporter 2 rime yped Nama f # <br /> H Signature Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> I.— 18b,Alternate Facility(or Generator) Manifest Reference Number: <br /> :3 U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> LU <br /> 18c.Signature ofAltemate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Typed Name Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />