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Pleaseprint o e- <br /> orrh pel` OMB No,2050-0039 <br /> UNIFORM HAZARDOUS D Number 2.Page I of 3 Emergency Response Phone1raCKinNumber <br /> , <br /> 9 <br /> WASTE MANIFE 7' r, <br /> -all h F L E <br /> S.Generator's Name and Mailing Address Generators Site Address(lf different than mailing address) <br /> Generators Pho-rle:-�', <br /> 6.Transporter 1 Company Na?ne U.S.EPA ID Number <br /> 7.Transporter 2 Compa;yiame7s <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> -71-d <br /> 0 <br /> t i5 J�- <br /> Facility's <br /> 9a, 9b.U.S,DOT Description(Inducing Proper Shipping Name,Hazard Class,iD Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(itany)) Na Type Quantity Wt./Val. 13.Waste Codes <br /> LU <br /> 2. <br /> LU <br /> O <br /> 3. <br /> 4, <br /> 14,SppciaJ Handing Instructions and Additional Information <br /> Ys <br /> 7j Z! <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper ship <br /> name,and are classred,pacEcaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemation shipping <br /> and 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 EPA Acknowledgment of Consent. <br /> J cerlify,that the waste mWmizafian statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(al am a small quantity generator)is true, <br /> Generatoes/Offeror's PrintedfTyped Name <br /> Signature,..-.- Month Day Year <br /> _j 16.International Shipments <br /> E Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> M 17.Transporter Acknowledgment of Receipt of Materials <br /> LU Transporter I Frinted/Typed Name <br /> W Signature, <br /> 0 Month Day Year <br /> 7 <br /> Z Transporter 2 PrntediTyped Name <br /> < Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Q..nfity Type ❑Residue ❑Partial Rj.cJ.r, ElFuii Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> Lu 18c.Signature ofAltemate Facility(orGenerator) Month Year <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 3.. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prmtedfryped Name Signature Month Day Year <br /> EPA Form 8700 <br /> -22(Rev.12-17) Previous editions are obsolete. <br /> :7 <br /> GENERAT <br /> OTS NMAL COPY <br />