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Please print or type, Form Approved, OMB 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 /> 5. Generators Name and Mailing Address � # 7 <br /> Generator's Site Address (if different than mailing address) <br /> 4% rzf <br /> jsrL? A A <br /> wCLK"l lne'_' , r4.. <br /> Generators Phoft64' v ZG67 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> f t L� r4tt a ru'CA <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address <br /> .u4f�'t,prt U.S. EPA ID Number <br /> 1j : <br /> Facility's Phone: <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Contalners 11 . Total 12. Unit <br /> HM and Packing Group (If any)) No. Type Quantity WL/Vol. 13. Waste Codes <br /> 0 ,1 =.10 iM N�E8RIVb i1 I <br /> LU <br /> 2. 1 <br /> 3Pie. <br /> 4. ) day / t1r t <br /> i <br /> v _ <br /> V k V, It r @� <br /> 14. Special Handling Instructions and Additional Information f <br /> ' r F <br /> tsSV 3E�D AND PIPE , <br /> . t L 6t _ ,f; t r f�C: 34Gr'"- fa(tP rt tf f t.iTN,t t€� r 1 �% <br /> r Fc <br /> 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, arra are classified, packaged, <br /> marked and labeledlplacarded, 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 EPAAcknowiedgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (di am a large quantity generator),or (bTotl am a small quantity generator) is true. <br /> Generators/0°t�fewrsPrinled/TypedsName Signafurp J I Month Day Year <br /> Z 16. Iritemational Shipments Import to U.S. } <br /> ❑ Export from U.S. Port of entry/exit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> >r 17. TransporterAcknoviledgment of Receipt of Materials <br /> w <br /> Transporter 1 Pnniedrryped Name :" Si nature Month Day Year <br /> t CL <br /> j Z Transporter 2 Printed(fyped Name Signature <br /> `1 Month Day Year <br /> 18, Discrepancy loll <br /> 18a. Discrepancy Indication Space quantity ❑ T <br /> YPe <br /> F1 Residue ❑ Partial Rejection ❑ Full Rejection <br /> WIN <br /> Manifest Reference Number. <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> a <br /> C) <br /> Um Fecilitys Phone: <br /> H1 Sc. Signature of Alternate Facility (or Generator) <br /> q Month Day Year <br /> Z <br /> 19. Hazardous Waste Report Management Method as (Le,, codes for hazardous waste treatment disposal, and recycling systems) <br /> D 1 2. 3 <br /> 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 /> Printed/Typed Name Signature --- <br /> Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete, <br /> GENERATOR'S INITIAL COPY <br /> I <br />