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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 T. Manifest Tracking Number WASTE MANIFEST L000U Z / i 020426971 5. eneralor's Name mand Mail Address ` r6 ! � A C G L Generators Site Address (if different than mailing address) ` 0 Generator's Aone: s. T atS �n .%fare , Inu . AI N?e 2 1 7 1 3 ��33 7. Transporter 2 Company Name U.S. EPA ID Number g�Dgin aleFa 'lite N e and Site ®dd �ycc [�+ ( U.S. EPA ID Number / aa Ice 0 Facility's Phone:440� ® 3 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. PL U 3. 4. 1 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. I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if 1 am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's Printed/Typed Name Signatur Month Day Year 16. International Shipments ❑ Import to U.S. ❑ Export fr . . Port of a exit: Transporter signature (for exports only): Date leaving U.S.: p� 17. TransporterAcknowledgmenl of Receipt of Materials LU Trans rter 1 Pri Ied/T ed me Signature Month Day Year p��i� t� c �� /0120 am� Transporter 2 Printedfryped Name Signature Month Day Year 9 F- 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ElResidue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J ommm rc. Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year 19, Hazardous Waste Report Management Method Codes (i.e*, codes for hazardous waste treatment, disposal, and recycling systems) LU 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DaI N TED AGILITY TO EPA's 04ANIFE [ SYST EM t