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Please print or type. Form Approved.Ol No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST <br /> JJ K <br /> r t l <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> t«iC9.1111i!Sot 9,J% PLAZA,5HIl <br /> Generator's Phon 9.69.'-;64 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> t ztfall:l ti t f �II"YL +�ArIEt ,'. i EsER it If4 L €b dC}Pt { <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> �?�i:•t�rlCs F� ���Et'�C:rM��:`lE'�'t <br /> 5115,53 E-1 iPIC O Iii <br /> rti$'1 .^3 <br /> Facility's Phone;""'.43 4g <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total V.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity wt.lVol. <br /> 1. -Sttt .TRr. fe �. . 'w 6nSzi <br /> o � <br /> ad , <br /> z 2. f": FLPIA-V"iti 1.is 9_3i.kf]t)F-.G 41C:. Cs"1.t:;;, 41 #,GI4LU <br /> t <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> E.P� <br /> I°[�h�'3i F'R:�, :�i¢�"•,?1.C1 �Y T'�.>wll�"� ;:P�Ci 1.!�� �G�tFet��':��') F+I��' _. ._... <br /> Ra <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internationaland 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 Cl 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Generator'slOfferor's Printedflypod Name Signature Month Day Year <br /> 16.International Shipments <br /> � ❑Import to U.S. Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> O <br /> 2 <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑l=ull Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facillty's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.HazaMOus Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />