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Please print or type. Frim Approved.OMB No.2050-0039 UNIFORM HAZARDOUS ��00 ber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Twkfng Number WASTE MANIFEST , L,33 7 g�� Yl�9 ye. Q 2 0 4 2 6 9 71 JJ K_. 5. eneratorrss N1 me�ailin Address �G, �Fj L L Generator's Sze Address(it different than mailing Address) r` pgz, & Z�1Z�j-M1 � Loor �4- rz yo Ge'iYll'CC/nt nneeratooes Ione: _r ._�- g5� %fI5— I. Cliwal rQomm Inc. �� A ID N Vba� 0 2 1 7 5 3 7.Transporter 2 Company Name U.S.EPA ID Number gJJand Site SIDE ,Tq �y�wG U.S.EPA ID Number Facility's Phone:_" 3�/ `- 9a . 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12,Unit 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity WtJV01. 0 q z 2. 3. 4. I 14,Special Handling Instructions and Addi[tio'nnal Information . 15. GENERATOR'SfOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by Iproper shipping name,and are classified,packaged, marked and labelediplacarded,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 Oft consignment conform to the terms of the attached EPA Ackmowledgment 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)(itl am a small quantity generator)is true. Gene�Ws/Offeror's Printed[Typed Name Signa Month Day Year r T � a •ti a d u 16.Intemational ShipmentsDImport to U.S. El Export f Part of a exit: Transporter signature(for exports only): Date leavi U.S.: W 17.TransporterAcknowledgment of Receipt of Materials LLI Transp r 1 Pri teffyped a Signature Month Day Year iS R c f d 1 GL _ 171/0120 Z Transporter 2 Printed/Typed Name Signature Month Day Year I � 8.Discrepancy 18a.Discrepancy Indication Space El Quantity F-1Type ElResidue ❑Partial Rejection ❑Full Rejection I Manifest Reference Number. 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ V I- Faclli 's Phone: W 18c.Signature afAltemate Facility(or Generator} Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes L.e.,codes for hazardous waste treatment,disposal,and recyling systems) 0 1. 2. 3. 4. I 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18o ' dnMfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM