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Please print or tvpe. (Form desioned for use on elite (12 -Ditch) tvoewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. T INITIAL <br />UNIFORM HAZARDOUS 1. Ge ngrtorID.Nme 3 6,� Y <br />2. Page 1 of <br />3. Emregecy RasponseFgne <br />4. M Tr k' r <br />b <br />WASTE MANIFEST <br />„ r <br />5. Genefator'aNarae„agd;Mailir /)caress Generator's Site Address (if different than mailing address) <br />61- <br />� 'S' . liv4✓. P <br />Generator's Phone: <br />6. Transl A- t )�P Tparly§ � !?., f.�3 m) a t.. z,s,.kt �E(_ .':: U.S. EtAl?'t ujnber <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated FaeiljtNarrLe_fJ)Steef#drets s U.S. EPA ID Number <br />Facility's Phone: <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any))No. <br />_ <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />Type <br />-; SwfV rv'=14P-4*%7Jw10;.,.4 a I;�i 2`, ...Jt' , f'"bvi' .x:?1 r"6 " {'r m -'FY <br />.... <br />0 <br />3. <br />4. <br />E <br />14. Special Handling Instructions and Additional Information <br />y g # <br />r'$k t Py$d ,°i .it'.# `.d ¢$i�.3fp.�tz 2((i..:JF.'�gt .1. e;:8 j(., ldsf i.'.:. 5.J?./1 �'#" 15 r? $.;$�i'/,�`.Y 'S..z�' ..t.,.. €.f, .t_'t .da'' {`'l+rPt` 6�ua":.'Vi t'9`;^O-ii.k .�;-x.,• t ..., .. <br />'3��.:+'»�'�v3' ..`$J�.,a'`'i l;;a z,,,.,ZJ � 3E�f'f i;.�'¢ :atlC'`..9 F.. �t Y�' W�"ail . ?i....�' ix�..P2 r'. A.d f I •�$�..) �zs..?��a`•�Y..�i � _ <br />15. GENERATOR'SIOFFEROR'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 quantity generator) or (b) (dl am a small quantity generator) is true. <br />4paderator's/Offeror's Printedfryped Namepature Month Day Year <br />�a S x <br />J <br />a- <br />16. International Shipments <br />❑ import to U.S. ❑ Exportfrom U.S. Port of entry/exit: <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter Pdntddfryped Name,, Signature Month Day Year <br />O <br />QTransporter <br />2 Printedfryped Name ° Signature Month Day Year <br />RECEIVED <br />e- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ <br />❑ ❑ft 8 2017 ❑ ❑ <br />Quantity Type Partial Rejection Full Rejection <br />a'lza TL' <br />18b. Alternate Facility (or Generator) /SERV CES U.S. EPA ID Number <br />.r <br />U <br />L <br />Facility's Phone: <br />W <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedfryped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. T INITIAL <br />