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Please pent or type. Form Approved, OMB No. 2050-0035 " <br /> UNIFORM HAZARDOUS 1 . an ID Number ' 2. Page 1 of 3. Erne en ResVnse�twne 4' Manifest Tracking Number <br /> WASTE MANIFEST D V g 1 gg - s - as 012329110 FLE . <br /> 5. Gen rator's NNaarq;� Mails Ad M �s I � D� © " ` f , Generators Site Address ('rf different than mailing address) <br /> 3 e�e,tT .��e Ir r <br /> �`e sao` <br /> Gen "' �'1 <br /> erator'sPhone. atD WQ <br /> 6gmnsporte, l Company Name U.S. EPA 1 Number <br /> IDRA *Of&A AK 00070 541D <br /> 7. Transporter 2 Com any Name U.SjEPA,�D m <br /> Loo t`t s ern file? <br /> e. De ' ted Facil' ame a it Adre U.S. EPA ID Number <br /> 130 <br /> AA C6 � a <br /> Facility's Phone: 519' <br /> 4 <br /> ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) No. Type Quantity Wtivol, 13. Waste Codes <br /> Z 2. <br /> W <br /> 0 <br /> 3. IS7 <br /> , <br /> I- <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> NIOA30 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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 international and 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) (d I am a large quantity generator) o ) if am a small quantity generator) is true. <br /> Generators/Offerors Printed/Typed Name Signati Month Da <br /> Y k <br /> 16. International Shipments <br /> i- ❑ Import to U.S. ❑ Export from . . Port of entry/exit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. Transporter Acknowledgment of Receipt of Materials <br /> T s erP ' sped ame Si atu Month �ay, YeX <br /> CL <br /> Z Transporter 2 PnmedrTyped Name SignaMINIMUM <br /> ture <br /> j Month Day Year t <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑ Type <br /> ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> c <br /> F� 18b. Alternate Facility (or Generator) Manifest Reference Number. r <br /> J <br /> U.S. EPA ID Number j <br /> Uall <br /> �a+ Facilitys Phone: <br /> W 18a Signature of Alternate Facility (or Generator) <br /> Q Month Day Year <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Uj <br /> 1 . 3. <br /> n 2. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item IZ <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev, 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM, <br />