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tint or Please p type, (Form designed for use on elite (12 pitch) typewriter.) _ Form Approved OMB No. 2050-0039 UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3 Emergency Response Plane 4 Man fest Tracking Number WASTC MANIFESTGBF 5, Generators Name and Mailing Address Generators Site Address (If different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name UI S. EPA ID Number 8. Designated Facility Name and Site Address US EPA ID RECT MAY 15 2017 Facility's Phone 9a and Packing Group if to g Shipping ID Number, to Containers 11 . Total 12. Unit 13. Waste Codes 9b. U S. DOT Description Including Proper Shl I Name Hazard Class, 0 HM g ( v)) No Type Quantity WtAso. 1 — — w z z w C9 3, 4. 4 ( 14. Special Handling Instructions and Additional Information 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 and 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. certify that the waste minimization statement identified In 40 CFR 26227(a) (If I am a large quantity generator) or (b) (III am a small quantity generator) Is true. Generator'slOfieror's Printecirrypetijigi Signature Month Day Year r Import to A. l 16. International Shipments - S Expel from U.S. Pod of entry/exit: ' z Transporter signature (for exports only): Dale leaving U.S.: w 17, Transporter Acknowledgment of Receipt of Materials Transporter 14'(Jnledfryped Name 1Y Sypalure `11 1 „ - %_ Month Day Year O ' — v w I V, VV QTransporter2 VentralName ' ' Signature ” MgNh 'Day = Year IV Ir 18. Discrepancy 18a. Discrepancy Indication Space , ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number, Ise. Alternate Facility (or Generator) U.S. EPA ID Number J U Facility's Phone: w 18c Signature ofAltemate Facility (or Generator) . Month Day Year Q z 19. Hazardous Waste Report Management Method Codes (i.e, codes for hazardous waste treatment, disposal, and recycling systems) IL 2, 3. 4. 20. D Name signate Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PriorSignature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. , ..