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1". <br /> Please D,rint or type. <br /> 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 r �( <br /> WASTE MANIFEST :�:Ei �? �eT 2 2M�-"tr;; JJK <br /> 5.Ce toss Name and Mailing Address Generators Site Address(if different than mailing ad r ss <br /> TI^?C?AJ. 1 r <br /> 4' P <br /> Generators Phone: �' Sok - €" F £ 'S 'j <br /> i <br /> 6 Transporters Company Name <br /> Qeuf'e a W, UW4.Im. U.S.EPA ID Number <br /> P.Transporter 2 Company Name U.S.EPA ID Number <br /> 8 ` U.S.EPA ID Number <br /> SALWAIGE LS <br /> Facility's Phone 161" = <br /> ga. Ob U S.DOT Desenphon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Padang Group(if any)) 11.Total 12 Unit <br /> No. Type Quantity Wt.Nol 13.waste Codes <br /> MAI <br /> w <br /> a 2. <br /> LU <br /> C3 <br /> 3. <br /> 4 <br /> 14 Special Handling Ins;uCtIons and Addifionaf Information <br /> R:Gf�� V1 r <br /> I lwk�A.C:'I;Y�a 1&1; � -Jt�Y. a.{ }','•fie�.�._ ,~ � �.*" <br /> 15 GI_NERATOR'SIOFFEROR'$CERTfF[CATION: I hereby declare that the contents of this oonsignmeni are fully and accurately described above by the proper shipping name,and are classified,packagjYe.r <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according,to applicable international and national governmental regulations.ff export shipment and i am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small ga9nbty generator)is true. <br /> GeneratoeslOfferors PdntedlTyped Name Signature • <br /> Month Day 16 International Shipments11 <br /> F ❑Import to U.S ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only) Dateaving U.S. <br /> 17 TransporterAcknowledgmenl of Receipt of Materials d <br /> aTran tiPrin Name Signature A( �7, <br /> g t b MoR1h Day Year <br /> X Transporter 2 Printed)Typed Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partiaf Rejection ❑Full Rejection <br /> 18b.Alternate FacilityManifest Reference Number: <br /> {or Generator] <br /> � U.S.EPA ID Number <br /> V <br /> LL Facility's Phone, I <br /> Ff8c SignatureofAlternate Facility tor Generator) <br /> Q Month Day Year <br /> z <br /> W19.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> [] 1 2. F- <br /> 20 <br /> 4. <br /> Designated Facility Owner or Operator:Cergication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br /> �x <br />