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Please print or type. Form Approved. OMB No. 2050-0030 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Nf umber [� WASTE MANIFEST C; ! t I ( j F!) > r OO 'z �3 f �I �/�� 5. Generators Name and Mailing Address r t 111 (.r 7 r IGenerators Site Address (if different than mailing address) It L tjrttiII IS&iaQfL7rtici Tu r I rA Ie IIIhch xic�ak F;, Ir „ C n ('16, G5,376 Generators Phone:- 2019 ,kQl -CW:' 6. Transporter l Company Name U.S. EPA ID Number In IIIIr1 F FriH�VI--C't f ICt r, fC.E J I (riD ."} GARO DI179'F47 7. Transporter 2 Company Name U.S. EPA ID Number ttr�;nHabxSEntiIx nfuc 8. Designated Facility Name and Site Address U.S. EPA ID Number G! n 1 <qx tT Jme, LLC x o e Facility's Phone: 4 (Kf-4.4. 1 -(); ( ga gb. U.S. DOT Description (including Proper Shipping Name,Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes HM and Packing Group (if any)) We Type Quantity aft./Vol.. . r t';4, vco c . (sU . , h , F vent rJr,"i, ,o lZil 01ft I , l t 15: I'f, , t � 4e `.lellf: ) , Ili 1 }.J );S 'i) 1 •I ( I�f`', 3. Yoe- k. Ci , I r � fF� L., r .r ( ( :r_lu Ctxs 11) Fo n t,Nnt If 4. t 14. Special Handling Instructions and Additional Information CaIII..,.x t Sr/ 5i f 41 1) CI r U3 ' 7fr. 2 ) CI ir, 1C r6 3 f '' f , ljGlf. .GCS ;o 't, trftl 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above bylhe proper shipping name, and are classified, packaged, 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 Exporter, I codify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262,27(a) (if I am a large quantity generator) or(b) (if I am a small quantity generator) is true. Generators/Offerors Printed/Typed Name fV Signature it. Month Day Year 16. international Shipments i— ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: z Transporter signature (for exports only): Date leaving U.S: W 17. TranspoderAcknowledgment of Receipt of Materials IW— Transporter i PrintedlTyped Name Signature r Month Day Year K az Tr7nspoder2 PrintedlTyped Name Signalurq - Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Padial Rejection ❑ Full Rejection Manifest Reference Number: r 186. Alternate Facility (or Generator) U.S. EPA ID Number J Ca LL Facility's Phone: w his. Signature of Alternate Facility (or Generator) Month Day Year a Z Fn19. Hazardous Waste Repel Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) Fn i. 2. 3. 4. � . 20. Designated Facility Owner or Operator: Cedification of receipt of hazardous materials covered by the manifest except as noted in Item its Prided/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY