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Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Ganeralor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mantest Tracking Number �{ <br /> WASTE MANIFEST i!�+_ fi4i) ?L8 �IA,Q i Fi 10 Ci4)-2122, 1 4 `� 5 4 ( FLE <br /> 5 Gererato's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generators Phone: 7.C<1 `''1/ l' 0 <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> t `w 17-nvnl)rrmcni'li Suh ll ort C:�6 (if}r1l�i!1f11 t1 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> I:r.' i" i1:K1T1.]I tit?rVir,i• MIK 431% ?i-i i r <br /> 8 Designelpdfacfli y Name and Site Address U.S.EPA ID Number <br /> r`(.`� `.�'• � �:'il:l I+i1/1'�;;(ti1i1)t?!h� <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> J 1 <br /> Non F2t";Rk'Hazz..IuOIiS <br /> 2 2. <br /> w <br /> CD -- - <br /> 3. <br /> 4. <br /> 1,4.SpeckalHaniflij�lnstructions and Addit"I.Infprn4atian <br /> .. r• r tr . : t <br /> • r t,.J('i�(Y t'Y C+^':�1��..r .'(-C'�, t?ll'.:i,�f.:�., <br /> 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, <br /> marked and IaboledJplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.11 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. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quardity generator)or(b)(if I am a small quantity generator)is We. <br /> GeneratorslOfferoes Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> I- ❑Import to U.S ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX W 17.Transporter Acknowledgment of Roceipt of Materials <br /> Transporter 1 PrimedlTyped Name r Signature / j Month Day Year <br /> a �,� ..j' •* - ,,`,� rhe t_ 't_f . <br /> 1[Ti;;5RW7FP;Rod1Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity 1:1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> W 16c Signatire of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> IU 1 <br /> 0 2, 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the snidest 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 />