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<br /> Form Approved. OMB No. 2050-0039
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<br /> UNIFORM HAZARDOUS
<br /> 1 . Generator ID Number =2, 3, 7mergencyRensponse, Phone 4. Manifest Tracking Number �+
<br /> WASTE MANIFEST _ .. ., . . .L ..) VES
<br /> 5. Generator's Name and Mailing Address T` fiirc iPi .S • : Lr:;, Generators Site Address (if different than mailing address)
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<br /> Generator's Phone:
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<br /> 6. Transporter 1 Company Name fj
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<br /> U.S. EPA ID Number
<br /> -7.-Transporter 2 Company Name
<br /> 8, Designated Facility Name and Site Address .Lt RG1..L= Kr', U.S. EPA ID Number
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<br /> Facility's Phone: ` i•' ' di •' •'•' Ll0
<br /> 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class; ID Number, 10, Containers 11 . Total 12. Unit 136 Waste Codes
<br /> HM and Packing Group (if any)) No, Type Quantity WtJVoI.
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<br /> 14, Special Handling Instructions and Additional Information ER a8i•7i cc tom,?;t)TS t I T VIE y)'5% -f• t7r'-r L'enk ir.� 1'y' ? :aA+nu= r ce%nfs_t
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<br /> e t1 -'_• t. rOI k $ 4 (r {,i .i71: 1 2 ' ,r5 t7 ' vi ri ilf) I �r � [ [I . � ItA 3 + T},'.'+rT: iF h� 4 `3 r?• tF`" (i 1) L6v ✓ �
<br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION: ( hereby declare that the contents of this consignmell III nt are fully and accurately described above by the proper shipping name, atd are classified, packaged,
<br /> marked and labeledtplacarded, and are in all respects in proper condition for transport according to applicable intemallonaland national governmental regulations. If export shipment and I am the Primary
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. enerator is true.
<br /> I certify that the waste minimizabon statement identified in 40 CFR 262.27(a) (rf I am a large quantity generator) or @) (ff I am a small quantity g F Month Day Year
<br /> Generatoestofferoes Printed/Typed Name 5lgnature , .
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<br /> 16. Intemadonal Shipments Import to U.S. ❑ Exportfrom U.S. Port of eniryleAt
<br /> �— Date leaving U.S.:
<br /> 2 Transporter signature (for exports only):
<br /> W 17. TransporterAftowledgmenl of Receipt of Materials Month Day Year
<br /> Signature
<br /> � TransporterlPrinted/1"ypedName Sign
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<br /> a _ Month Day Year
<br /> Transporter 2 Printed/Typed Name Signature
<br /> 18. Discrepancy
<br /> r ❑ Full Rejection
<br />` 18a, Discrepancy Indication Space ❑ T e ❑ Residue ❑ Partial Rejection
<br /> ❑ Quantify yP
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<br /> Manifest Reference Number.
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<br /> U.S. EPA ID Number
<br /> 18b. Alternate Facility (or Generator)
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<br /> ua.. Facility's Phone: Month Day Year y
<br /> tW 18c. Signature ofAltemateFacility (oreenerator)
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<br /> 19. Hazardous Waste Report Management Method Codes pa,, codes for hazardous waste treatment, disposal, and re1 11cycling systems)
<br /> 3. 4.
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<br /> 20. Designated Facility Owner or Operator. Certi8callo of receipt of hazardous materials covered by the manifest except as nded in Item 18e Month Day Year
<br /> PdntedfTyped Name Signature
<br /> EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete.
<br /> GENERATOR' S INITIAL COPY
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