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RECEIVED BY SJCEHD (EF) on 3/25/19 <br /> Please print or type,(Farm designed for use on elite(12-pitc}1)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS <br /> Generator ID Number 2.Pae 1 of 3 Emergency Response Phone 4 Manifest Tracking Number fl <br /> WASTE MANIFEST v tit . . :mJJK <br /> i Generators Name and Mailing Address Generators Site Address{if different than mailing address) <br /> Generators Phoneme`- <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address i t, Cs:lfry s: U.S.EPA 1D Number <br /> 95 <br /> Facility's Phone: <br /> g� 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, u.. 10.Containers 11,Total 12.Unit <br /> HM and PeckingGroupif an " Quanti wt.Nol. 13.Waste Codes <br /> 1. iris-q z (Past• _ '-eP1 p iP 3 KK1 <br /> Z 2. <br /> LLJ <br /> Ur <br /> 3. <br /> mow... _. <br /> 4. I <br /> Special Handling lnstructions and Additional Information <br /> 16, GENERATOR'SIOPFEROR'S CERTIFICATION: I hereby declare that the contents oft (s consignment are fully and accurately described above by the proper shipping name,and are classlfied,.packaged, <br /> marked and labeledlplacdrded,and are In 6E1 respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement ldentlfied In 40 CFA 262,27(a)(if I am a large quantity generator)or(b)(ifl,am a small quantity generator)is true. <br /> GeneratorslOfferor's Printed(Typed Name Sigir it re Month Day Year <br /> -1 16.lntornational Shipments <br /> i- ❑Import to U.S, ❑Export from U.S. Port of entrylexit: <br /> ? Transporter signature(far exports only): Date leaving U.S.: <br /> 17.TransporterAcknowledgmantofReceiptofMatedals <br /> Transporter 1 Printed(Typed Nam�e,� Signature � � � Month Day Year <br /> VCx '& v ❑,&.^t.F g d:. ' r <br /> z Transporter 2 PrintedlTyped Name 1. - f Signature Month Day Year <br /> Ice <br /> Y' <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residuej j <br /> ❑Partial Reaction Full Rejection <br /> Manifest Reference Number: <br /> F� 18b,Alternals Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month bay Year <br /> Q <br /> Z <br /> L" <br /> Hazardous Waste Rel Management Method Codes(Le„codes for hazardous waste treatment,disposal,and recycling systems) <br /> d-r ri 2. 3. 4. <br /> F <br /> 20.Designated Facility Owner or Oporator:Cerlification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PriniedfTyped game f Signature- F t Month Day Year <br /> �� �� f 1 y if'rs'£ �•`Y' �€ �T�, tl�l/"� -rrf � �y5,��i'�'r �'',��i,•"L'�.^�,�. a;'fes' - `� � ��. <br /> FPA Form 8700-22(Rev:'3-05) Previous editions are obsolete, <br /> L)ESIGNATED CaNEFtO „ <br />