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Please print or type. Form Approved. OMB No. 2050-0039 <br /> I . Gene ator ID Numb 2. Page i of 3. Emergency ResponsePh 4. Manifest Tracking Number <br /> 11NIFORM HAZARDOUS � � (^t DAT WASTE MANIFEST tt"'.t � ( t � 4 o i � l l f'1 <br /> 5. Generator's Name and Mailing Address I re 1 ( ) _ Generators Site Address (if different than mailing address) <br /> 1tkC. Ir,� r c { �c. 1LI4� - tlocr l ,'- h Fie_ap,( <br /> III <br /> `i 1R! Lcra rP hi•:s '?'f <br /> I I } GSA iF F C PAPS 4,7 1 <br /> Generators Phone rr) t <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> I riFfin IS r. �.1 1 GAP f t : J -„c: ( .� r tesx.� It ii : . . �+ � GA>,ft'10 'I7 �7 " 7 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number _ <br /> DdiF.rdfiltvt, r� uetl'. t' f ` ,. u C / r7:3r�',2 > >�3:; <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> C' oU 1lz Ftmm nciij- r " , . if , 'S 1 , 1- l �Re-)0p 1 311 lei <br /> IN <br /> Facility's Phone: 2(Vt 2�0- 2.461 <br /> ga 96. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM q9 and Packing Group (if any)) No. Type Quantity WI rvu. <br /> K i I :..',ti/, I 1 . , 1 , I <br /> Z <br /> ! Mor f eIe IfJ PIjq ( <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> r., <br /> V. <br /> L..Ft a f �n_r r I frr , � ; <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 Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable internationaland 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 l am a large quantity generalor),or (b) (ifI am a small quantity generator) is true. <br /> Generators/Offerors Printed/typed Name Signatures' Month Day Year <br /> 16. International Shipments t to U.S. <br /> i— 11Im Import ❑ Export from U.S Port of entrylerit: <br /> ? Transporter signature (for exports only): Date leaving U.S.:% <br /> pe 17. Tran'spoterAcknowledgment of Receipt of Materials If <br /> e- Transporter 1 Printed(Typed Name 7 Signature Month Day Year <br /> az Transporter 2 Printed/Typed Name Signature Month Day Year <br /> K <br /> F- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: . <br /> 18b. Alternate Facility (or Generator) - U.S. EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w iBc. Signature of Alternate Facility (Or Generator) Month Day Year <br /> Q <br /> Z <br /> 19. Hazardous Waste Repot Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> n <br /> L 2. 3. 4. <br /> 20. Designated Facility Owner or Operator: CetiGcation of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Printedryped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />