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Please print or type, s T ;r;; Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of f3 Emergency Response Phone4.4.Manifest Tracking <br /> °Nuumber <br /> WASTE MANIFEST �r� ``''8'6r y � ( � d 4" `��we677 ( � ! �#�� �� <br /> 5.Generator's Name and Mailing Address F5,191 <br /> r Generator s Site Address(if different than mailing address) <br /> �(.✓��f�r a �,Ur� �i�tri ��t�ft'ta°B��=fi d�4�f <br /> '71111 <br /> +e r._ r .ns•✓ Y��+� rtt:•ttt.9 r.'.F�fLi-f• t,.+�°� <br /> General is Phone: s <br /> 6.Transporter <br /> 1 Company Name{ $� // }q/� / U.S.EPA 100 Number j /f{/, JI <br /> �O' Gr;vl ,tip YrY'1 J' `./2 J 1 l W'1 C✓ - I� J'h+ _/b�✓ f 49 e? <br /> 7 Transporter 2 Com y Name ` U.S.EPA ID Number f <br /> t , <br /> 8.Designated Facility Name and Site Address !� , ! / f ^', U.S.EPA ID Number <br /> •tf.,f �-llf'G.=�L,'IGfG"�. 1,0„ <br /> Ij 307 <br /> 'acility' Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity'' Wt.Nol. 13.Waste Codes <br /> o .�/����} i' 1r .� j ;�` ,t.. ,3 {Zai <br /> Q �t{}pr ?y {�1rrS t' c')I�.�r lrtf':s'S at���W!Pi`� •} �• ' W <br /> Z 2. <br /> w <br /> a <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 4 1-7 <br /> 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, <br /> 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 <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 identified in 40 CFR 262.27(a)(if I am a large quanfitygenerator)or(b)(if I am a small quantity generator)is true, <br /> Generstoesl0fferoes PrintedlTyped Name Sigla,'uref f Month Day Year <br /> A, <br /> 16.Intemational Shipments~ <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials 7 <br /> Transporter �rintedfryped a7 Signature Month Day Year <br /> CL <br /> �-� <br /> Z Tragsporter 2 Pdntedfryped Name r Signature tMonth Day Year <br /> r 1 <br /> 18.Discrepancy ; <br /> 18a.Discrepancy Indication Space ❑ Quanfily ❑Type <br /> El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Ntemate Facility(or Generator) U,S.EPA ID Number <br /> J <br /> V - ' <br /> Q+•• Facility's Phone: <br /> F18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 3. <br /> 14. t <br /> '20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. TRANSPORTER COPY <br />