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i Please print or type. 1,:. f ",; Form Approved.OMO No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST :_ r; r :; a ., 014 "T u FLE 5.Generator's Name and Mailing Address,.I. Generator's Site Address(if different than mailing address) t.f`_�.. -tom:�� 1.:'. tv Generator's Phone: 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 Facility's Phone: 3I 1 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. � 1.• - .. ref,,: `�' '? ,+` c ,r.. ', a 2. W C7 3. 4. 14.Special Handling.lnstfuctions and Additional Information 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,vd 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 Ex orter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I ertify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(by(ifl am a small anfityge'rator)is true. Gen aloes/C!5 rmr's Printedrryped Name 1 , Signature / / /! Month Dpy Year ,J 1� International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? T)ansporter signature(for exhorts onl): Date leaving U.S,; W, I T._ransporterAckno edgmentofReceiptof,MaterialsLU ^ ranspoTt�r 1\me y ame S inatu,e�_ ) MPnth D Xg r Z Transpoftr2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection t x• ❑Full Rejection i Manifest Reference Number: 18b.Alternate Facility(or Generator) I.T.S.EPA ID Numbet _J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. t 2. 3. 4. Ll20.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 Dayer EPA Form 8700-22(Rev.12-17).Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR J