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Please print or type. _ Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.MantlesI Tracking Number <br /> N <br /> WASTE MANIFEST "t•G =ate= �'1�-2 <br /> ' ' -49"1 02040,3223 JJ K <br /> 5.Generators Name and MailingAddress Generators Site Address(if different than mailing address) <br /> BIG VALLEY AVAI 1 V Pd <br /> 7S315 UNDEI4ER13H 31, <br /> SIOCKTON,GA 95215 <br /> Generators Phone: e0'y-9C�t'dS1r <br /> 6.Transporters Company Name U.S.EPA ID Number <br /> Ge}rge 11'r".Lorwly,IrfC, CAFOY)a47019 <br /> 7.Tran sporter2 Company Name U.S.EPA ID Number <br /> 8.0>'gqLe ci��NNaa epn S(eadtlress U.S.EPA ID Number <br /> Sr�XL.Uf%rc'f:cGEi �Inc. <br /> 1217 r.FIESTA Ave. <br /> A2 <br /> PARKER,#.R x5544 <br /> Facility's Phone:S20-664-_T=2 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Padang Group(if any)) No. Type Quantity M.N.I. <br /> 1' <br /> Na-4 RCRA. t•iri,7.--noUG WASTE scuo (pap€r la!ic 011 111ters) OP.t P .352 <br /> 0v <br /> W <br /> z 2. <br /> W <br /> 3. <br /> 4- <br /> 14.Special Handling Instructions and Additional Information <br /> ERG#170 paper&036tk 04 mer'3 <br /> USE GLOVES PMAteff 1P�.fC7i �e4 1�0C 0ra) l <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,am are Gassed,packaged,, <br /> marked and IabeWIplacarded,and are in all respects in proper condition for transport according to applicable inlemational 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 EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if1 am a large quantity generator)a(b)(ifl amfa small quantity,generator)is true. <br /> Gene loesiueroi`PdntedlTyped Name Signature r f Month Day Year <br /> t. <br /> 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. J Pod of entrylexit: <br /> ? Transporter signature Qcr exports only): Date legging U.S.: <br /> W 17.TransporterAc owledgment of Receipt of Materials <br /> ui <br /> Transporter 1 PrintedUypedame Signature Month Day Y ar <br /> Me <br /> aTransporter 2 PrintedfTyped Name Signahfre ,r Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantic ❑T ❑Residue <br /> y Type ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generalor} Month Day Year <br /> a <br /> z <br /> rn <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />