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<br /> PieasUNIFORM HAZARDOUS 1 Gene afa 10 Number I��3.. Me!
<br /> I�II�I I I form Approved.OMB Nn.2050-0039 v
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<br /> WA5T7 MANIFEST ' '! t';ih4''+ t Nt4' 2.Page 1 a! l Rasupanse Phone d.Manifest Tracking Number F L CD
<br /> 5 Generalar's Nemo and Mailing Address
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<br /> B-Designated FaGGIy Name and Sate Address �- ., - ,.. U.S.EPA ID Number �
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<br /> ga, 9b.U.S-DOT Description(inddi,g Proper Shipping Name,Hazard Class,ID Number,
<br /> HM and Packing Group{danyy) No Containers ,1.Talal 12. ol. 13.Waste Codes
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<br /> 14,SpeciaE:Hand;1rNIns1j,-ucbun-s and Additional Information i, i:'-10 r+
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare Ihal the contents cf thls mrsignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
<br /> marked and Iabeleelplacarded,and are in all respecls in proper condition for transport according to applicable irlematianaland national govemmental regulations.If export shipment and I am fie Primary
<br /> Exporter,I certify that the contents of this consignment cwntmn to Me leans of the attached EPAAcknuiviodgmeot of Consent.
<br /> I Cal that the waslb minimization statement iden15ed in 40 CFR 2$2.27(a)(if I am a large quantity generalarJ or(b)(III am a small quantify generator)is We.
<br /> Generatorsiolil is Prrledlfyped Name Signalum",
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<br /> 157hlemalronod Shrpmenls
<br /> � ❑import to U.S. ❑Export from U.S. Port of enlrylexit:
<br /> Z Transporter signalum(for exports only): Dale leaving U,S.:
<br /> Ix 17,Transporter Admowledgment of Raceipl of Materials
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<br /> l TranspoRer 1 Pnnledl7yped Name Signature Month
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<br /> Z TranspoRer 2 Printed/Typed Name Signal
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<br /> 18.Discrspancy I�
<br /> 18a Discrepancy lndcellon Space Quanhly Type Residue❑Residue
<br /> ❑Partial Rejection ❑Full Rejection
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<br /> Manges.Reference Number:
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<br /> 1$h-Altemata Facility{or Generator} U.S.EPA ID Number D O
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<br /> emenl Method Godes(i,e.,codes'Cr hazardous waste treatment,disposal and recyGmg systems) (.)1
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<br /> r or rabr.Certdicauon of recelpl 01 hazardous maiurials covered b the manifest except as ngad N Ifam 18a � O
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<br /> A Form 8700-22(Rev.12-17} Previous odiGona aro Obsolete. f RAjnr j'$,N�7rAL CUF Y
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