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1 � <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C2,11356 1 r e fiesJ 13 <br /> , ` G : F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: 209 2.'-4•,7 F0 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Pq) `A.'/ ,.livironmenral`citutions trAUD0(lM6(.1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Numbor <br /> I C ±rtdustrtai Servlur MHK 435 nd; 74.2 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> . .r <br /> Facility's Phone: �) iii X11 m'V I'S 1!)(i?0ILIII'' <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Tota' 12.Unit 13.Waste Codes <br /> HM and Packing Group(it arty)) No. Type Quantity Wt.lVol. <br /> Nwi-R(;RA Hia- arciotis Vconte. Soi,d '5'ebris) <br /> z 2. <br /> LU <br /> c7 <br /> 3. <br /> 4. <br /> 14,. �1 lipp. ;;If iInsbuctions and Additim � <br /> Unlo abco <br /> �• <br /> - Yi7 .r11 <br /> ('trikt, 01014*'083V-25181 <br /> �1v1Ci�f'�E�4�CY (,0N 1A('1' JEFF RHODVI." <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and aocurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelelflplacarded,and are in all respects in proper condition for transport according to applicable in'•emational and national governmental regulations.M 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 AcknovAedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ii I am a"a quantity generator)or(b)(di am a smal quantity generator)is true. <br /> Generator'slOfferor's PrintedlTyped Nan Signature I Mont Day _Year <br /> j 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Prot of entryloxd: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Adurowiedgment of Recept of Materials <br /> LU <br /> Transporter 1 PrintedlTyped Name ( Signature / Month Day Ytar <br /> a y ' <br /> d' Transporter 2 Printedfrypod Name Signature Month Day Yea, <br /> 1•- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity 1:1 Type EJ Residue ❑Partial Reyection ❑Full Rejectcn <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U. Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> Fm19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1• 2. 3. 4. <br /> 20-Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />