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Please print or type Form Approved OMB No 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 or 1 3 Emergency Response one d.ManifestTracking Numher WASTE MANIFEST FLE S 5 Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transperter 1 Company Name 1J EPAID Number 7 Transporter2ComtrignyName U S EPA Q Number 8 Desrgnaled Faulty Name and Site Address US EPA ID Number Faa s Phone: 9a, 9b U S DOT Description(including Proper Shipping Name,Hazard Class,ID Numb,r, 10 Conlainers 11 Total 12 Unit HM and Packing Group(if any)) No Type Quantity Wt Not 13.Waste Codes occ I � a z 2 w c� 3 4 —� 14 SpKialHatmtl nq 1wiLruclif,rm i0Addlii o;ii Infr Tri.iln• 15 GEN ERATOR'SIOFFEROR'S 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations If export shipment and I am the Primary Exporter I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262 27(a) 'I am a large quantity generator)or(b) w:a small quanLty generator)is true GPnerltnrs OtTnro' Pnritedflfyped Name. f rdurM Payr fear O$ 1,411 7t> _J t6 Mtamauilhal Sh,prn:ri'a r— ❑Import to U S Export from U S Port of enlry/ex h ? lranspert !KI1ahue tot oxportsgnty)- Date leavnq U S W 17 Transporter Acknowledgment of Receipt of Materials LU liaresporlm 1 PhnW'TypBd Name Signature PAnnlh Day roar O a D a �d Z Transporter 2PrinledilTypedName Signature Month Day Yrar 18 Discrepancy 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Mcarr{fr+c+Reference Number' r 16b Afierrrale Favi q(or Generat(r) US EPA ID Number J U rarlrty's Phone: W 1 Be Signature of Alternate FacTity(or Geriera!or) Month ay Year a z 19 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal.and recycling systems) NJ 1 2 4 20 Designated Facility Owner or Operator Certification of receipt of hazardous maleriais covered by the manifest except as noted in Item 18a Pnnl VPgd Manu! 1ignalvo Vorilh Day fear EPA Form 8700-22(Rev 12-17) Previous editions are obsolete.