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-7-77 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.tNaaifestTracking Number <br /> OWASTEMAN E50US "4,d � 53 JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 47'lii,W\:'tA..TWJti! <br /> ?�rtFid . l f117t f E x W <br /> Generators Phone 1' '• t'f > <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i'V%il tlF:s 3qu S 3tiiF�i , 47Afl S �','1t: tkk ti: C r �C , a;C? <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address, � t9 ` ' ht„F U.S.EPA ID Number <br /> t5lR -' <br /> Facility's Phone"f Fr,`-,J-t747' <br /> ga 9b.U.S.DOT Descdption{including Proper Shipping Name,Hazard Class,IQ Number, 11}.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. <br /> Crf 1” ,, ii'! 4C :r`.;+. i'1A:4AK00US V?V%r - f-M �-QlM (CON L, MV..Fd4 <br /> O <br /> ru <br /> z 2 <br /> w <br /> C7 <br /> 3, <br /> 4, <br /> 14,Special Handling Instructions and Additional information <br /> -;�,4,t]l �;WtJW FJE TRkW,0 AND i!JSF APF>R0VLQi <br /> 15. GENERATOR'SlOFFEROR'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 intematlonaland 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)(if I am a large quantity generator)or(b)(if]am a small quan�ily generator)is true. <br /> GeneratorslOfferor's PrintedfTyped Name Signature -' Month Qay Year <br /> 16.International Shipments <br /> F,. ❑Import to U.S. ❑Export from U.S, Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> Z Transporter 2 PrinledlFyped Name Signature Month Day Year <br /> ti <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> F-1 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Numher <br /> J <br /> U <br /> ra Facility's Phone: <br /> 18c,Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> Fn. <br /> ated Facility Owneror Operator:Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> ed Name Signature Month Day Year <br /> EPA Form 87DO-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />