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Please print or type. Form Approved, OMB No. 20504*0039 UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Aunt r.►ddn 47mber r WASTE MANIFEST r IF* zIII . 'fir , D L 5. Generator's Name and Mailing Address Generators Site Address different than mailing address) Generators Phone•.' 6. Transporter 1 Company Name IF U.S. EPA ID Number �c:t ,. S•.` 7. Transporter 2 Company Name U.S. EPA ID Number , . `" ' a: . .a 8. Designated Facility Name and Site Address U.S. EPA ID Number FIN&a Irk Facility's Phone z.LF gar 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12, Unit 13. Waste Codes HM and Paddng POW (9 any)) No. Type Quantity WUVol. 1 , a mak`. , .. : � a ,E. ,`- ,.-qi : •: SS ir ' ct§ C. , rr. Sei :�i ' z' � a xd' -r`}, i '3ES . iA4,t zCr it,, s . . - LU 2 3. tt 4. 4. 1 14. Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROWS 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, marked and labeled/placarded, and are in all rsWls in paper condition national governmental regsde5ar& it axporf slti thent and ! am the y Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment 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) (01 am a small quantity generator) is true. Generator Offer7ce PrmtedffypedName Signew <A Month Day Y J $ I. tc.•a C ' A :s f E e % r.F' NIPPON mj 16. International Shipments El Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: 17. TransporterA jknowledgment of Receipt of Materials TransporterNama Signatu Month Day ear o. for 1 14441 Cl Tran ser 2 e yped N are Month Day Y r 18. Discrepancy 18a. Discrepancy indication Space El Quantity ❑ Type ❑ Residue ❑ Parfaf Rejection ❑ Full Rejection Manifest Reference Number. Or 18b. Alternate Facility (or Generator) U.S. EPA ID Number I � V FacilitysPhone: UJI 18c. Signature ofAlfemate fatality{or Generatori MoftDay Year z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1 . 2. 20. Designated Fatality Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item f8a Print ' yped Maine nature onto . - _ ear t EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DMC41ATO FACLIT v T 0 ERPS �MAAIFESTSYSTEM