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<br />Form Approved, OMB Na. 2060-0039
<br />EPA Form 8700-22 (Rev.12-17) Previous editions are obsolete.
<br />GENERATOR'S INITIAL COPY
<br />UNIFORM HAZHAZARDOUS1.
<br />Generator ID Number
<br />2: Pa�ye lot
<br />3. g Emer Res P one
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<br />4. Manifest Tracking Number
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<br />WASTE MANIFE5T
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<br />5�¢llprs Name and Mailing Address Generator's Site Address (if different than mailing address) -
<br />ddress)1,3GON-
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<br />Cenerator's Phone:
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<br />7. Trans orter 2 Com any Name U:S. EPA ID Number
<br />8. Desi, naffed Facili�! Name and Site Address U.S. EPA ID Number
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<br />V210 VENERNT WAD, ;
<br />FRMOMA R.S. W36
<br />Facility's Phone: tov)
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<br />gb. U.S. DOT Descrlp(ion (Including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />No,
<br />Type
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<br />and Packing Group (if any))
<br />Quantity
<br />Quantity
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<br />14. Special Handling Instructions and Additional Information
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<br />15 GENERATOR'81OFFEROWS 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 labeled/placarded, and are in all respects in propor, condition for transport according to applicable intarnatioraland 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 EPAAcknowledgmert cf Consent.
<br />I certify that the waste minlmization statement identified in 40 CFR 262.27(a) (if I am a large quantity gonera(or) or (b) (if I am a srrM quantity generator) is true.
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<br />Gone r tar'slDHeror"s Printed/TypedName ,�Month Day,+ Year
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<br />16.InternationalShip mants
<br />❑ I mport to U.S. ❑ Export from U.S. Port of entrylexil:
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<br />Transporter signature (for exports only): Date ieaving U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials
<br />Transportor 1 Printod/Typed Name Signature i ;t Month Day Year
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<br />Transporter 2 Pdnledrryped Name Signature 'F� Month bay Ye r
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<br />18. Discrepancy
<br />18a, Discrepancy Indication Space Quantity❑ T ❑
<br />Type Residue Y ❑Partial Rejection �. ❑Full Rejection
<br />Manifest Reference Number:
<br />18b, Alternate Facility (or Generator):. U.S. EPA ID Number
<br />Facility's Phone:
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<br />18c, Signature of Alternate Facility (or Generator)
<br />Month Day Year
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<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />1,
<br />2.
<br />20. Designated Facility Owner or Operator: Cerlificagon of receipt of hazardous materials covered by the manifest except as noted in Item 188
<br />Prinled)Typed Name Signature Mi Day Year
<br />EPA Form 8700-22 (Rev.12-17) Previous editions are obsolete.
<br />GENERATOR'S INITIAL COPY
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