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Please print or type. Form Approved. OMB No. 2050-0039 11 UNIFORM HAZARDOUS 1 Generator ID Number 2. Page i of 3. Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST l.;/ 7 r t r r rT r ' r 00D DAT 5. Generator's Name and Mailing Address /-J IGenerators Site Address ( f different than mailing address) ( f . . ; 11 < =rR b dLot1IIt .rL �: - 89 C . atii ( t .rs Generators Phone. 6. Transporter 1 Company Name U.S. EPA ID Number f; itf " ` 1 if ;i)p;l r: 74F 7. Transporter 2 Company Name U.S. EPA ID Number rilc J Hi i)r,( u( t .CG- _ ( l „1 ,. 1': r . B. Desg p1 d Facility Name and Site Address U.S. EPA ID Number tt r s :.) E '^ Facility's Phone: ga 9b. U.S. DOT Descriplion (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity WENol. K z 2. W 3. 4. r 14. Special Handling Instructions and Additional Rearmafo ,e•c -ar. nl ti �, G; u .:1,b. _wt f , . , . , 1r � ,aU , . i .: 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, atd are classified, packaged, marked and Iaheledlplacarded, 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 Exporter, I cer illy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I codify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b)(ifI am a small quantity generator) is time. Generators/Offerors Printed/Typed Name �,j- Signature `"Month Day Year 16. International Shipments F ❑ Import to U.S. ❑ Export from U.S. Port of entrylexil: ? Transporter signature (for expels only): Date leaving U.S.: n 17. TranspoderAcknowledgmenl of Receipt of Materials - F- Transpormul Printed/Typed Name t Signature Month Day Year Z Transporter 2 Printed/Typed Name Signature Month Day Year a 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V <a Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2 3. A. 20, Designated Facility Ovmer or Operator: Certification of receipt of hazardous materials covered by the manifest except as acted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions areobsoieter GENERATOR'S INITIAL COPY