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Form Approved.OMB No 2050.0039. <br /> Please print or type. 2.Page 1 of 3.emergency Response Phone 4.Manifest Tracking Numbor <br /> UNIFORM HAZARDOUS 1,Generator ID Number y� syJJK <br /> WASTE MANIFEST 641 f ou... 3 ' e' <br /> y Generator's Site Address(if different than mailing address) <br /> 5.Generator's Name and Mailing Address V 1`i P I t ! ',k �"d t <j r ,Pj " !' <br /> ¢^ '' <br /> r <br /> 1,� x r� ii f cwt 's: <br /> knerator's Phone U.S.EPA ID u��J}{bar <br /> 6.Transpr 1 Company Name <br /> U.$.EPA ID Number <br /> 7.jra9sporte 2 Company Nam@ <br /> 1t,; p} t l:t t t 1 C-'. t �:.. r 7 <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address r �l�, � r c Zee, 'r,►w"J 4"' , <br /> '�;,r.,tt+� ,^�;�4%�,.,�ECj?;�..�� f�:f�.t''�:3'�ff�� �,�e`..t• �.j,?i('.),�� �,��w�Ferl�•����°" '�Z�'+�'''` <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,HazardClass,ID Number, 10.ContaMe11.Total Wt Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Quantity Wt.Nol.1. Ntm 3 ' <br /> yr ( <br /> Z 2. <br /> UJ <br /> c� <br /> 3. <br /> 4. <br /> Special Handling Instructions and Additional Information l.' ( 0 to e- <br /> 14. •-' �} , <br /> i, A'd�r"11,x&�� ;• <br /> �+T`!C"•' ''�L�'r�:� �nd <br /> �,ccuraflbed <br /> 15. GENERATOR'SIOFEEROR'S CERTIFICATION:.Ihereby declare hat the contents of this consignment are fully by the proper shipping name,and are classified,packaged, <br /> marked and labdiedlp"lacardedr 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 <br /> Exporter,I certify that the contents of this consignment conform to'the'terms of the attached EPAAcknowledgment of Consent. <br /> I certify thak the waste minlmization statement(dehtifled in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. M n Day Year <br /> Generator'slOfferor's PdntedfT ped Name Signature.-, <br /> 0. <br /> F16.Intema al Shipments ❑import to U.S. ❑Export from U.S. ' Port of entry/exit: <br /> M Transporter,signature.(for exports only): Date leaving U.S: <br /> 17.TransporterAcknowledgmentofReceipt ofMaterials <br /> Transporter 1 Prl tedlTy;pqd Name Signature ` ` M�nih ay Year <br /> CL <br /> Month <br /> Da-y� tYiel <br /> J <br /> =Tpan 2 PnntedTyped Name Signature <br /> �� � is `, i r,.. , �`'`�i.�,,?(.� •._,11r. f;;..- L� I _. <br /> 18,Discrepancy <br /> 18a,Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> LL Facility's Phone: Month Day Year <br /> I w 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> i Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> o b 2' 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipfof hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> Printedfryped Name Signature <br /> EPA Form 8700-22(Rev,12-17) Previous editions are obsolete. TRANSPORTER COP <br />