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--^- Farm Approved,OMB No.2050-00$9 <br /> Please print or type. t Trackin Nwnber1.Generator IQ Number 2.PageJT!7!=4. - 9 y I <br /> UNIFORM HAZARDOUS 1 J J K <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Skte Address(if different than mailing address) <br /> Generator's Phones'°'' � U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> P�:k.m{.1s Frw13ioItlb+lEWAL-31EiIS II1Ii:, <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA f0 Number <br /> a.Designated Facility Name and Site AddresspA��i£.pfz 1"-1 >vf?tF-C.(YVER+' <br /> 316D EAST PILO X93,VD. <br /> Lot's-4birMLES,SVA ~002 <br /> C'Z041- EAS <br /> Facility s Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 14.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group{if any]) No, Type Quantity Wt.Nok. <br /> Lr <br /> Z 2. <br /> LU <br /> 0 <br /> 3. <br /> 4. _. <br /> 14.Special Handling Instructions and Additional Information <br /> t�F�t;a3tSi:tit <br /> M,"RAMS 3 PPO usr- AP1'ROVIE,D 14.1-. <br /> 15. GENERATOR'S10FFEROR'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 labeledfplacarded,and are in all respects in proper condition for transport according to applicable intematlonaland national governmental reguiafions.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in AD CFR 26227(a)(if I am a large quantity generator)or(b)(ifl am a sma 11 quantity generalor)is true. Month Day t Year� <br /> Generator`sfOlferor's PrintedfFyped Name Signature <br /> J 16.International Shipments ❑Import to U.S. ❑Export from U.S.' <br /> .S Part of entryfexit <br /> ZDate leaving U.S.: <br /> Transporter signature(for exports only): <br /> W 17.TransporterAcknowledgment of Receipt of Materials NYearLU <br /> mnth QTY <br /> Transporter 1 PrintedfTyped Name Signature f N, 1 t <br /> 0. Month Day Year <br /> Z Transporter 2 PrintedlTyped Name Signature <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑❑ Ouankiky Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J_ <br /> U � <br /> LL Facility's Phone: Month Day Year <br /> W 18c.Signature of Allemate Facility(or Generator) <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 2G.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> HniedlTyped Name Signature <br /> GENERATOR'S INITIAL COPY <br /> EPA Farm 8700-22(Rev,12-17) Previous editions are obsolete. <br />