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_ r <br /> Y ' <br /> please print or type. Farm Approved OMB No.205_ <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3 I<merge-cy Response Phone 4.Manffg4t Tracking Number <br /> wAsri=_MANIFEST at CW 3 trW SS 7 q't[t6 .6.714 JJK <br /> 5,Generators Name and Ma7ing Address G,r'j P Geiera'-{'s Site Address(idifferent than mailing address) <br /> PC)1cy- 611 ai u CI&,r-4-,o �-/ <br /> 6q1t ,571q 51czll4uA 95 aUb S{�lclL�vn <br /> '')rSqP'h0na—: <br /> B.Trans=-e- <br /> Company Name US EPA ID u ber <br /> T l C <br /> 7. ra porter 2 Company Nam U. .EPA ID Number <br /> 6,Designated Facifity Name and Site Address r ` f 4 Y U.S EPA D Number <br /> r 16av rE• �'�^ LA' <br /> Taci5, s Phone: <br /> ga gb.U.S.DOT Descripllart(including Proper Shipping Name,Hazard C ass,ID Number 10.Containers 11 Total 12 Unit <br /> HM and Paddng Group{d any)) No Type Quantity WLIVV 13 Waste Codes <br /> /1 Ij <br /> lrt�s� �5,�-• <br /> LU z. <br /> ry <br /> ca <br /> 3. <br /> 4, <br /> 14,Special`HandlirV(Instructions and Additional Information ( p r' <br /> C) �, S <br /> V-04& a;� 15-18--C,. e7Z <br /> 15, GENERATOR'SfOFFEROR'S CERTIFICATION,I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpphrg name and are classified,packaged, <br /> marked and fabeiedoacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> porter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I certify that the waste.minimization statement klentKed in 40 CFR 262.27(a)(t I am a large quantity generator)or(b)('rfi am a smafi quantity generator)is true <br /> GeneraloPsfOtferoes�� Name� � Signa, Day year <br /> 16.InternaMal Shipments <br /> ❑import to U.S. ❑Export hum U.5 ,� Port of entrylexii <br /> Transporler.signatum(for exports only) Date leaving U.S.: <br /> W 17.TransporfarAcImmsiedgment of Receipt of Materials } <br /> F Transporter 1 Pn tedff Name Signature ` Mq�th ay Year <br /> O •Tr1 { f L� I I S ` I t t 11' <br /> 9L r <br /> z TfarrsAanar Frintedlfyped Name <br /> Signature � 1�lonth Day Yea <br /> 18.Discrepancy <br /> 18a.Discrepancy Indica7on Space ❑ Quantity ❑Type ❑Residue v ❑Partial Rejection ❑Full Re ectton <br /> Manifest Reference Number. <br /> 18b.Aftema'.eFaa3ityiorGenerator) �"U.S EPA IDNumber <br /> L) <br /> Faa1Hy's Phone <br /> Uj 18c.Signature of A:tamate Fad;ity(or Generator) Month Day Year <br /> a <br /> z <br /> 19,Hazardous Waste Report Management Method Codes I'.e codes for hazardous waste treatment,disposal and recycling systems) <br /> UJ 1 _ z 3 4 <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materlals covered by the manifest except as noted in Item 18a <br /> Print Signature Month Day Year <br /> EPA Form 8700.22(Rev 12-17) Prev nus editions are obsolete TRANSPORTER COPY <br />