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asavy, w.tip s Please print or type. Form Approved.OMB No.2050-0039 FGeneratoes ARDOUS I.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.A4artifesf Tracking Number pp NIFEST 4 9 �D it me and Malting Address 0061HGenerators Site Address(if different than mailing address) �y t.,A! - (`J Generators Phone �"' Pl� 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number i v Ir - e Facility's Phone:— ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM and Packing Group(if any)) 11.Total 12.Unit No. Type Quantity Wt.Nol, 13.Waste Codes rri r t iNO i v;j, u;4A;517^FCAMrNIAbt i l iii N c! � rc�Ec ;Jtiq ;c� tz W i Z 2. W 3. 1 19.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 EPA Acknowledgment 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. Generatoes/Offeror's Printedfryped Name Signature Month Day Year Gs V 1 .,,c 16.International Shipments ❑Import to U.S, ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): -__ — -- -- Date leaving U.S.: OC LU 17.Transporter Acknowledgment of Receipt of Materials Transporter Manch Da Yepr CL 4 2 Tra rt er 2 rint d Name Signature Month Day f e r (T 18.Discrepancy v� 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 11.- 186.Attemate Facility(or Generator) U.S.EPA ID Number t� LL Facility's Phone: W 18c.Signature ofAltemate Faculty(or Generator) Month Day Year a Z 1 W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 9. 20,Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted In It Prntedffyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. nCC1f_`K1 ATen t 11]TV"M"n a . r I a arsrce r av�Tes,