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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number 1 WASTE L 1 U " ^437 VES 0` 'Z) 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number L 1'4 I'M455L Ey S.REET 131C HW-1tirl. -A 9401 Facility's Phone: �,i-1, .;-,., ;:q',I� ..- A P �4 !"t 9 9a. 9b.U.S.DOT Description(including 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 Wt.Nol. 0 2. >F-k HAZARD,3t T,z"'MA STE W"U'D. CLATMk PA114T, L 3. C U, rVAS-1 R SOL!D, -140V-Pi7B 4. 14.Special Handling Instructions and Additional Information ER,SeMC* bV VMS + Cottract ret miced b,4 zw?neraV%r 1ranstr(svpir to Ad or v �ner%on qeueravfs hiharl -I- 4bstime addided3l tran 5 ti -I L',-.P 5 5 A477 PL UqJ-0 I ,54 11- CP 3)7 2 0 843 A-SLM-�3 5 34 15. GENERATOR'S/OFFEROR'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 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 the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generator's/Offeror's PrintedfTyped Name Signature Month Day Year ,I , J V 7.j 16.International Shipments 1.- 1:1 Import to U.S. ❑Export from U.S. Port of entrylexit: 9 Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials UJ Transporter 1 Printed/Typed Name Signature Month Day Year 0 czo[Transporter 2 PrintedfTypecl Name Signature Month Day Year 9 1 1 1 1 18.Discrepancy 18a.Discrepancy Indication Space El Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Zi 0 LL Facility's Phone: 0 LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 LLI 1 2. 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY