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Please print or type. Form Approved, OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. M°°ayynifest T„ racking Number pp WASTE MANIFESTg a rtJCtxc T:1 , 1 �J GDF 5, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number ILti: t;titx r: `. ,M 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number = d +$ ttI� JIIi t ! I %° t«)i rtt' k a {',j, tit :nik � w., r ISE.EVA ilk°, , i = £ ; E ; c §l . . , 1 °- : f [ 1 . b .37p : fs& ,� l`,o�-StF 89. 400 Facility's Phone:' � 9a. 9b, U.S. DOT Description (including Proper Shipping Name, Heard Class, ID Number, 10, Containers 11 . Total 12. Unit HM and Packing Group (d any)) No. Type Quantity WtNolo 13. Waste Codes . . it k , wr3 . 3 . I r .. Rf�C 0zS k�tixA- t r ;ski ! 11 's , i+l . C; ` yi41 I_ F, [:; , L3 sca r a C;j O w 0 3. 4. 14. Special Handling Instructions and Additional Information tytid 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international aqd national governmental regulations. If export shipment and i am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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. ad NameSigp+ 7e ,, o ro s rin atur Month Day Year � . n )P Ik IIIIj 16. International Shipments r. ❑ Import to U. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: IIIINNNIONIN1Z IT Transporterftnowiedgment of Receipt of Materials Transporter edrryp ' ame Signatur Mo D y ear O Idle INFO tz Tran rtr to yped Name gnature Month ay Ye 18. Discrepancy 18a. Discrepancy Indication Space El Quantity ❑ Type El Residue El Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number V LL Facility's Phone: h18c. Signature of Alternate Facility (or Generator) Month Day Year at Z 19. Hazardous Waste Report Management Method Codes (Le', codes for hazardous waste treatment, disposal, and recycling systems) 1 . 2, 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev. 12-17) Previous editions are obsolete. DESIGNAT ED FACHU O EPA's e4AAM FST SYSTEM