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Please print or type. Form Approved.OMB No.200.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST (W on 1. I >i1�_r+r{1-;� ? 013846423 FLE 5.Generator's Name and Malang Address Generator's Site Address(d different than ma7ing address) , Generator's Phone: 09- ?3,Y 7700 6,Transporter 1 Company Name U.S.EPA ID Number 0,q G): L=nuiicinm0of So(iltloll C.400034G01C' 7.Transporter 2 Company Name U.S.EPA ID Number i-t,! Inai46110 Service M.X 43!, 642 1 8.Designated Facility Name and Silo Address U.S.EPA ID Number Facif spheno: /.�-J ga. 9b.U.S.DOT Description(indud ng 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 WINoI. 1. Il anMot15 V,'aste, Solid (Debrle) Z 2. LU t, 3. 4, 14.S ial Handling Instructions and Additional Information 15- GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are tatty and accurately described above by the proper shipping name,and are classified,packaged, marked and laboled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulatons.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgmenl of Consent I corny,that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(0I am a small quantity generator)is true. Generalofst0fleror's Printed/Typed Name Signature Iknth Day Year 16.International Shipments 1- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: - Z Transporar signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Yea, a Z Transporter 2 Printed/Typed Nam Signature Month Day Year a ; 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Dull Resection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number : e U u- Fasilitys Phone. W I8c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 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 PdntedlTypW Name Signature Month Day Year EPA Form 8700.22(Rev.12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY