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RECEIVED BY SJCEHD (EF) on 4/20/2020 Please prfnt or pe.(Formdesi nedforuseonelite(12-pitch)typewriter.) Form roved.OMB No.2050.0038 h' 9 tY APP UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ,nl ,,�rh. F,., ;7 .r 008631923 F L E 5.Generators Name and Mailing Address enerators tie Address(if different than mailing address) pe"C6 '319 209478-1726 541✓fa P-krifi.c Avenuw 540b PRcifie Avcnuz Generator's Phone: !;4. r r ro Q-=iPf i .9j-n r t n ii, i:A grin 7 { 6.Transporter 1 Company Name U.S.EPA ID Number r`}tom r i r-vi-1 p CZ tip ri l{:v l ,f'� qn l rrf 'nrr. 7 r• If1f+;r.rrsr71 7 GgP4 7.Transporter 2 Company Name U.S.EPA ID Number s�'7''� �Di.-`�vr' YYT�r'r o♦ t��c�'%GA ! /�hif^.l/r_fes.� ,� !� l I�9e� dGG1_/O G�� 8.Designated Facility Name a e Address f r'�itAddAen::rai t17VIrOnrlUtl;.r`ll lint, LLCU.S.EPA ID Number 11855 :'.hire Runt RoPLI ~ Renci-te Cordova, GA 95742FadlitySPhOne' rgg, rnnnnn Ren-. ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11,Total ~12.Unit HM and Packing Group(if any)) No. Type Quant ty Wt.Nol. 13.Waste Codes I 1. X RP, NA3077, Havirdrui- waste. solid, n. u.s. i OF 13'3EaO P 181 0@9 Glewciiry), 9� IAC, ll[- M09) z2. LU Xj1�!19=i1; Wa,i:•� Aeru:,Oz, Flit:ijable; Gi thyl a I,F tTO Oh P 3:41 31001 10,005 Ethy?. Ketone), '. 17 ERC-0126 N Ci"PIMB; TDxiC; ).i.quids, arrganic., t-,.o, S . 2 OF GOii5 P 331 Ocr thrin, Pipz;' nnyl Psltaxide)9 6, 19 PGITT r-mfln# I Non-Regulated ElWaatc, (i=lryctrnniL 17eiice;); 1 CE= 00091 P 14.Special Handling Instructions and Additional Informat*n 1. 103575(13rclten LilGps/ Bulbs) 2: (AerosoIs Lonsepar_k) 3. i =i:r ?_(Toxic Liglk d. Organic (Nart -RCUTA) ) 4). MS79(Electroni.0 Weste) 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 labeiedlplacarded,and are in all respects in proper condition for transport according to applicable infemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identkd In 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. eneratorsl0 erors Printedffyped Name // Signatore on ay Year .�a'--Q dl /Lf cx j- '-P [I B 1 f at c o� t 1 9 aul G 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entryfexil: r Z Transporter signature for exports only): Date leaving U.S.: rY 17.Transporter Acknowledgment of Receipt of Materials LW Transporter 1 �aPrrintoedfuf (r� l y Year Pm gnatureIL I/ 1qf .IOIb N Mme. ' Z pbrtet 2 Friniurryp6d Name ignature Month -Uay oar a 18.Discr' ancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, 18b.Ntemate Facility(or Generator) U.S.EPA ID Number J_ - C.1 a ' Facility's Phone: Ll 18c.Signature of Alternate Facility(or Generator) Month Day Year F Z Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. I 3. 4. 14IL11 20.Designated Fqeiitydvneror Operator:Certification of receipt of hazardous materials covered y the manifest except ps noted in Ite 8a 113rinteciffyPeWame Signature Month Day Y r --( Ve-� 6L EPA Form 8700.22(Rev.)-05) Previous editions are obsolete. iGA'ATED FACILITY TO G,5WRATOR STATE(IF REQUIRED)