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Please print or type . Form Approved. OMB No. 20$0&00. <br /> 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phune 4: ManifestTraoking Number <br /> UNIFO[2M HAZARDOUS + <br /> 4f% <br /> y : 9 s 5 , � t t ., V <br /> WASTE MANIFEST d 1 % i ; " ) t ' ? s t 1 r s < J J K <br /> 5, Generator's Name and Mailing Address 1Generator's Site Address (if different than mailing address) <br /> r r ;: , � OX <br /> , <br /> w <br /> it c <br /> I'l It <br /> enemior s Phone <br /> b. Trains} ortor 1 Company tName U.S. EPA ID Numbor p <br /> 7. Transporter 2 Company Nanta U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address ? , , - U.S. EPA ID Number <br /> It <br /> rk' + rt � `J7 y �3 .' C, .... . ln . ✓f✓� 't{+' i `' .! d <br /> tFacll tjts Phone: <br /> 9a 91), U.S: DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12, Unit 13. Waste Codas <br /> HM and Packing Group (if any)) No. Type Quantity WtlVol: <br /> 0 ftiq <br /> V <br /> 2. <br /> 4 . <br /> iJ ---- <br /> 14 . Special Handling Instructions and Additional Information - <br /> xA ENT AL <br /> = t <br /> ENVIRC <br /> f <br /> 0EPA T t <br /> ifi <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare filet file contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeled/placarded , anti are in all respects in proper condition for transport according to,applicable intomationaland national governmental regulations, Il exportshipment and I am the Primary <br /> Expottor, I coraly that the eontents of this consignment conform to the lentis of the attached EPAAcknowiedgmentof Consent, <br /> I certify [hat the waste minimization statement identified In 40 CFR 282.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> GenoratoiW0ffemr's Printed/Typed Name Signature Month Day Year <br /> ,j 16. International Shipments rr-� <br /> i-- 1-1 import to U.S. u Export from U,S, Port of entrylexit: <br /> K Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TtenspoderAclinMudgmentofReceipt ofMaterial$ -Poo <br /> Tiansporier 1 Printedrfyped Name Signature ! ,,x Month Day Year ., <br /> F <br /> a' Transporter 2 Printed/Typed Name Signature Month Day Year <br /> w <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space Qr,antity Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> `4t <br /> 181). Alternate Facility (or Generator) U.S. EPA ID Number <br /> W Facility's Phone: <br /> ruj 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> tt 19, Hazardous Waste Report Management Method Codas (I.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU 1: 2. 3. 4 . <br /> i <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials'cavered by the manifest except as noted In Item 18a , <br /> Printed(fypedName L Signature ; , ',*` Month Day Year <br /> q <br /> y < < i <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br /> TRANSPORTER{ COPY <br />