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111111111111111 Formpp Approved.OMB No.2050-0039 <br /> Please print or type. 2.Pae 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number 9 013693984 F L E <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> n a.-#14- .=_. <br /> 'U.S EID Number <br /> Generator's Phone: -- PA <br /> 6.Transporter 1 Company Name <br /> f-4 <br /> U.S EPA ID Number <br /> N7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 570, Facility Name and Site Address <br /> xtF,r sir <br /> _ t0.aC <br /> Facility's Phone. }� <br /> 9b U S:-DC T Descdptrori(irfciading Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Totar 7 l nrt` 13.Waste Codes <br /> 9a. No <br /> HM and Packing Group(if any)) Type Quantity Wt.Nol. <br /> z `ie'it ttlsfi <br /> Z 2. <br /> W <br /> U' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <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 classifieddged <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am th <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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Month <br /> Generator'sI0 P inte yped Name Signature <br /> _j16.International Shipments �Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> UJ Transporter 1 PrintedlTyped Name Signature <br /> O <br /> a ,. Month Day Year <br /> Z Transporter 2 Pnrited1Typed` ame Signa e <br /> F <br /> 18.Discrepancy <br /> El <br /> Full Rejection <br /> 18a.Discrepancy Indication Space � Quantity ❑Type Residue ❑Partial Rejection ❑ <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> I Facility's Phone: Month Day Year <br /> OL 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> Q 1 ' <br /> 1111112. 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in It 18a Month Day Year <br /> Printedrryped Name <br /> EPA Form 8700 22(Rev.12-17) Previous editions are obsolete. DESIGNATED C{CITY TO EPA's a-MA IFES SYSTE <br />