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type. Form Approved.OM B No.2050-0039 4.00 M HAZARDOUS 1.Generator 1D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST t"v.'��,i��l�:fi#�1�; , JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's PhoneV4)a46 6.Transporter 1 Company Name U.S.EPA ID Number ts.lNlfx3; lir tl r�rAil .Bsy sKt-a 4'.r1: IN 7-Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address . . U.S.EPA ID Number 1511 i0LIlfii'� . r�T SAG 11if0,G-A, S15F t1 Facility's PhoneJ 15--`x'1`"'74 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 WVVci I. HON P5'R,C F1A2AR XJl . WASI-Em &rRM (NIL,t` ID.1;.1al ;� .„ `• f '� O W C7 3. 4. i 14.Special Handling instructions and Additional Information 7 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, marked and Iabeledlpiacarded,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,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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)(ifI am a small quantity generator)is true. Generator'sl0fi s PrintedlTyped Name, Signature Month Day Year 0 _j 16.International Shipments � ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: 0� 17.Transporter Acknowledgment of Receipt of Materials LLI Transpprfer 1 PrinledlTyped Name Signature Month Day Year Z Transporter 2 PrintedlTyped Name Signature } Mont Day ear' Q 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 J U Facility's Phone: LQ 18c.Signature of Alternate Facility(or Generator) Month Day Year a1 Z 19.Hazardous Waste Report Management Method Codes(i.e"codes for hazardous waste treatment,disposal,and recycling systems) 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 Printedfryped Name Signature Month Day Yeas EPA Form 8700-22(Rev.12-17) Previous editions are obsolete GENERATOR'S INITIAL COPY