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MOD Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number Q 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST e QZ OzA [ 0 ��7Z Z5 012329117 FLE 5.Generator's Paine and Mailing dress p _ I nerator's Site Address(if different than mailing address) C a1 ItzDV Ia, 100. � i ��`�C wt tY enP -Ccs Wl �2s0 L� �H H G Let ✓GP t c,A-a r3 _ Generator's Phone: 7, 6.T nZter Company a 1- �. U rT easya 7.Transporter 2 Company Name U.S.EPA ID Number 8.Doss n d Fact ly Name and Site Add ss U.S.EPA ID Number � u� ck7o �''1°` . arc, L q��s Facility'sK P o a: ` ga 9b.U.S.DOT Description(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.Nol. 1-NQPCVS zardcu5 Wmsk � LU 11� � f D r Z 2 W 1, 3. 4. 14.Special Handling Instructions and Additional Information 171113 5 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare INA the contents of this consignment 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 international and national governmental regulations.If export 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)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. Generator'sfOfferor's Prinvay ama Signature Month Day Year 16.International Shipments P- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgme t of Receipt Of Materials 1i Trans 1 Printedfryped N me Sign Day Year , a r■Y'�I�j� •-7 2s Qo z Transporter 2PrintedlTy Name Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manliest Reference Number: 18b.Alternate Facility(or Generators U.S.EPA ID Number J_ V Facility's Phone: uuj I Sc.Signature of Alternate Faculty(or Generator) Month Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1 2. [A� I 20,Designated Facility Owner or Operator:Certification a i"pl of hazardous materials covered by the manifest except as&In Item 18a Print Signalura onth ay �e� TWO EPA Form 8700-22(Rev.1 -17 1e ' use ons are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM