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111111111111111 <br /> Please print or type. Form Approved.CMB No.20544439 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 0— Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 12. <br /> ---- 013120749 F L E <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phcne: } ? <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> ^ , --J R ,)(-),l <br /> ss5 1 7 2 <br /> 8.Designated Facility Name and Site Addre „Iy, tf^) a N U.S.EPA 15 Number <br /> _ T <br /> t; <br /> Facili s Phone"; — <br /> ga go.U=S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit <br /> HM and Packing Group(if any`)) 13.Waste Codes <br /> No. Type Quantity WL/Vol. <br /> t . rl e m o-` -- r 'sC t �t:,�1— <br /> F- ubzt %5f zcl id, Tax _z => <br /> cin} h}- T u`Y e - i <br /> Z 2. <br /> W <br /> C7 <br /> z <br /> 4. <br /> 14.Special Handling Instructions and Additional Informationt <br /> 1¢ i t vr'*4 NE ''Cr_tY"r C C:rkGi.EiTf g ti3a tti neer 1t.oreseert# Lamp` <br /> r <br /> 15. GERERATOR'SIDFFEROWS 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 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 <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 GFR 262.27(a)(if I am a large quantity generatyr)otr )(if I am a small gyiantity generato true. <br /> Gene 2 ONerars Printedlfyped Name rg ur Month Day Year <br /> �C7YG� I r I0,- I1!; lntZ <br /> F- 1 emat orra[Shipments F <br /> ❑Import to .S. Export.r U.S.` PoR of ant /exit: <br /> ? rensportsr sigralure(hrr ergots only): Date leovi U.S.. v <br /> W 17.Transporter Acknowledgment of Receipt of Materials 4 <br /> UJ <br /> t-- Transporter 1 PrintedfTyped Name Signtture^^ Month Day Year ; <br /> l t/9X N' R <br /> O <br /> U) rfi 0rr.' ct'yt 'Ili �'�r ."x <br /> QTransporter 2 PrintedfTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEl �Type ❑ j ❑Full Rejection j <br /> Quantity T e Residue Partial Rejection � <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> J <br /> LL- Facilitys Phone: <br /> w 18c.Signature e`Alternate Facility(or Generator) Month Day Year <br /> F l� <br /> z -'t <br /> 19.Hazardo `A ste Report Maqagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) _ <br /> 0 1. 2. 3. 4. <br /> 20,nnS F Owner yr Operator: e tifr on pt ace t hazy dous materials covered by the manifest cept as n d in em 18. <br /> 1'rin Name <br /> Si lure J <br /> L7 month <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESlG ATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />