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L M N <br /> - pledsp,e e - O - -i <br /> O - 0 N N <br /> Z -- -- --- - W ON C <br /> DPlease print or type. <br /> t1NlFORM HA2ARDOl15 r Generator to Number Farm Approved.OW No.2050.003 CD <br /> I WASTE MANIFEST :Page 7 or 7.Emergency Rasp—Phone 1.ManNaelTncking Number Q <br /> D K 3 <br /> z 5 Generators NWong and ifna Address "' JJ <br /> Generalols Site Aduress(ir diHerenl than mailing ad9nass} CU <br /> M � <br /> Z N <br /> W Generators Phone. v < <br /> 6,Transporter 1 Company Mame <br /> U.S.EPA 16 Number 0 <br /> Transpoder 2 Company Name >_ <br /> U.S.EPA VD Number <br /> S 0eaigrraled Facility Name and Site Address <br /> U.S EPA ID Number (/r <br /> Q <br /> Fa:ilitv's Phone: - 3 <br /> ga. 9b.U-5.001`Desrrtphon(mendingPru r Shipping 0) <br /> pe pping Name.Hazard Glass.IQ Number. 10-Containers Q <br /> Hh! and Racking Group nranyll 11,TOlal l2.Unit y� <br /> I No, Type Quantity WI^/ol. is3-Waste Codes (D <br /> C V) <br /> Q' O <br /> [�7 kD <br /> v <br /> W <br /> r. N <br /> r� <br /> W <br /> O <br /> U- <br /> LA <br /> (D <br /> 14.Spec al Handling Instructions and Additional Inlormalion <br /> (D <br /> dc�c <br /> G <br /> r+ <br /> S <br /> 15- GENERATOR'SIOFFEROR'S CERTIFICATION:i hereby declare that the contents of this consignment are fully and accurately described above by me proper shipping name,and are classified,packaged, Ort <br /> C <br /> marked and iabeledlplacarded.and are in ad respects in proper condition for transport according to applicable irtemai and nadonai govemmental regulations.If export shipment and I am the Primary 0) <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cert**that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large uanti Q- <br /> g q Ty generator)or(b)(l I am a small quant ly generator)is true (D <br /> Generatorsi0ffemr's PdnledlTyped Name Signature Monty Day Year <br /> CJQ <br /> 7 <br /> J 16.International Shipments � <br /> Z ❑import to U.S. ❑Export from U.S. Port of entrylexit: ((D <br /> Transporter signature(far exports only): Date leaving U.S.: ' Q <br /> C 17.Transporter Acknowledgment of Receipt of Materials n <br /> w O <br /> Transporter 1 PdnledlFyped Name Signature Month Day Year -0 <br /> O <br /> W <br /> Q Transporter 2PrintedlIYpeelName Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> F 18b.Alt re Facility(a(jenerator) Manifest Reference Number <br /> U.S.EPA ID Number <br /> U <br /> LL Faciliiys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> O CD <br /> (Q (7 <br /> O <br /> Fn 19 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal,and recycling systems)LU <br /> v Q <br /> O 1 2 3- 4. <br /> 20 Designated Facility Owner or <br /> C2C �k <br /> Operator Cert fica@on a1 receipt of hazardous materials covered by the manexcept as noted in Item 1Be <br /> PrintName <br /> Signature Month Day Year 00 <br /> v W <br /> EPA Form 6700-22(Rev.12-17) Previous editions are obsolete. _ <br /> GENERATOR'S INITIAL COP rn <br /> w <br /> 0 <br />