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Please print or type. Form Approved, OMB No. 20500039 f. Generator ID Number 2. Pzge 1 of 3. Emergency Response Phone 4, Manifest Tracking Number UNIFORM HAZARDOUS 02 ""' 00 � t c F 9 i jl{ WASTE MANIFEST u (_ 1 = tom !' '=' i + ff { �& s� '� li� E1 L,S ',�t tk �. ( 1J1J1 � 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) C: 1 ! rf_, r:c? r c� i,tea . Lzte � . < �t i ; i 1 `w mo ;=art ~,'_ ' , I (.il lIskiF� '�i Generator's Phone: 5. Transporter 1 Company Name U.S. EPA ID Number Ponder Inf:: 7, Transporter2 Company Name U.S- EPA ID Number 8, D eg4nated FadlltyNam and Site Address U.S. EPA ID Number t ,s f,CCit0 �]'OF t " 5 G' l7 >� B e l'Y , ! �•' �1!�Us Facillty's Phone: f liiij ( .( ' 13 � ijti j G000 ga. 9b. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tolal 12. Unit 13, Waste Codes HM and Packing Group (d any)) No. Type Quantity WtNol. O 1 t` ! `� f1• I 1� [` ?'. l ? ��t �Gilc R a fC . I tCjl ii ( ` L ?rf Z 2. ��v N � ,2c f2ILI ► i + ca (Z 7 au5" vJ +q Lr I Oki 3. I 4. 14. Special Handling Inswcilons and Additional Information F1 i') 4T461SAI 0 _lcb W2C•• 601 u 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable inlamational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment canfomr to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantify generator) or (b) (ill am a small quantity generator) Is true. fenerator'slOfferne Pd tedRped Name Signature f ��i'^� � Mo Day Year r 16. International Shipments ❑ import toU .S. El Export from U.S, Port of entrylexit: i Transporter signature (for exports only): Date leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials Transporter I Printed[Tyfped Name Signatuiar� '_ Month Dai Yea rr zransporter2 Printedrryped Name Signature Month Day Year r- 18. Discrepancy 18a. Discrepancy Indication Space ElQuantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Re!bcdon Manifest Reference Number. F 18b, Alternate Facility (or Generator) U.S. EPA IDNumber Z U Lai. Facility's Phone: Aionth Day Year w 18c. Signature ofAlternate Facility (or Generator) Q z 0 19, Hazardous Waste Report Management Method Codes like., codes for hazardous vraste treatment, disposal, and recycling systems) n213. 4. i 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Year PrintedlTyped Name Signature Month Day mill EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR' S INITIAL COPY I