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Please print or We, <br /> Forrn Approved.OMB No.2054.0439 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,MandW Tracldng Number <br /> WASTE MANIFEST �- � � � u• _ - `� :.' 019839144 JJK <br /> 5.Generafars Name and Mailing Address Ganerator's Site Address(if different than mailing address) <br /> Generator's Phone: 0440ZLCA�52G3.AT7ti:Gonnyksffaan�iGy��� <br /> 6.Transputer 1 Company l l ime <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Wme lu �r <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address ... U.S.EPA ID Number <br /> 1.121 IItl3 G{rfs iLC37ii[v3 ''v'i�Til±%e <br /> d�Jki �v eiG a,.:lii?irJl rl'.sr3=1 ._ <br /> _Fadrd es Phone: <br /> 98. 1 9b.U.S.DOT Description(including Proper Shipping Nitre,Hazard Class,ID Number, 10.Containers 11.Told 12.Urdt <br /> HM and Packing Group(9any)) Nc. Type QuantityWkNd. 13.Waste Codes <br /> `- <br /> � <br /> a LIAI Y <br /> 2. <br /> 3. <br /> 4. <br /> 14.Spec+al . ndlingInstructioisandAddttionatKormation <br /> p <br /> 15. GENERATOR'SIOFFEMR'S CERTIFICATION: I hereby declare 0hat'the contents of this comignment are fully and accurately described above by the proper shipping rte,an l ate classified,paqkagad= <br /> marked and labeledlp[acarded,and are in all respects in proper condition for tnimspot according to appkahle intemational and national governmental regulations.0 export shipment and I am the Primary <br /> Exporisr,I ceAHy OW the nts conteof this consignment W*rm to the lemic of the attached EPA Adumledgment of Consent. <br /> F Certify that the waste minimizatthn statement iderdifred in 4t1 CFR 262.27{a){iF t arra a large quantity ger>erator)or{b}{rfl am a smati uarnti <br /> PrtntedPlSipad Name q iy generator is 4ue. <br /> 3yae! Mordh Day Year <br /> 1/9 <br /> Cl y t Import to U.S. ❑Export from.U.S. ort of entrylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TranspoterAckrwwledgment of Receipt of <br /> T hyped a 1115nature hkrtth Day Year <br /> f <br /> Name <br /> re Y <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quark ❑Type Residue ❑Partial Rejecton ❑full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Y Facilitys Phone: <br /> LOU 18c.Signature ofAsmite ridroy(or Generato) <br /> Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(is.,codes farhazardous waste treatment,disposal,and recycling systems) <br /> 1• 2• 3. <br /> 20.Designated FaciNty Owner or Operator.Certification of receipt of hazardous materials covered by.(he manifest except as noted in Item 18a <br /> Pnnted Name Signature MDM Day <br /> EPA Form 8700-22(Rev.12.17) Previous edisone are obsolete. DEPA'sLITT 0, <br />