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Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page I of 3 Emergency Response Phan 4.Mant.{if',est Tracking Number WASTE MANIFEST :,�L:3.- ::15;D >~7 j , { = JJ K 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) • '•t:!%r`r`�'i'i;f_-,Iri11�1(,s/T7r�r�1U�1•^ ��'�C: $�t;i}'',s,�'','*.,�.r::it�^:fJ". U��Sf L��-uC�ilC'*arGr•- k�=�/�•__ Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U,S,EPA 10 Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone:?t'� ' '4747 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 WUVOI. ne 1. 'siu Eirr'r.' i! �iieiA?I-t "b°aMyi t.. .,t��iD lrt} Bf�15Yt._ �. -. W z 2. W 3. 4. 14,Special Handling Instructions and Additional Information 3 L- .Z ya t;c csiJri }1 GM71 tom/+i tUt,' 10 Eilw Tfti5d.4EG ril'40 ;SF ',?-PHGjED PPE E R. s:ry}lirf+[:FGF'. RA790 nn,,}t of if:W{•'f,�_ ,:6 u; ',E!r r ( � 15. GENERATOR'S10FFEROR'S CERTiFtCATION:1 hereby declare that the contents of this consignment are fully add,accurately descdb5d•,above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,and are In all respects in proper condition for transport according to ap table mtemaOPnala national�ovemmental 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 EPAAck edgrpentof Conserrt I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity gegeratoi or'(b)(it amfa dmal�qv`nlity generator)is true. Generator'slOBeroesPdntedlTyped. ame Signature' '- 't k i k y Month Day Year "�{_'�J r7_'1'"'i`'' 'rr �`,^`^-..,l.�-•'��.5.}":�...�....�........�.. - .1 16.International Shipments ❑Import to U.S. ❑apm from U.S. Part of entryfexit ? Transporter signature(forexportsonly): Date leaving'U.S.: UJ 17.TransporterAclmowledgment of Receipt of Materials Transporter I Printedgyped Name i Signature Month Day Year CIO Transporter 2PrinledlTyped"Nape' Signature Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number U uQ Facilitys Phone, W 18c.Signature of Allemale Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4, 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prinledrryped Name Signature Month Day Year EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED FACILITY COPY ,r,fnr l nr rnfrn ruin 49AMIrr-OT vnr r JAIM DeeonMcIM11 rrr_a trnln!•=la'rWr-e.MeidlCF..RT Af:T qFF INIRTRIIr'.Tif1NR ON RFUFRRE SIDE.