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RECEIVED 3/25/2019 Please print or type,(Form designed for use on elite(12-pito}1)typewriter.) Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1..Generator ID Number 2.Pae 1 of 3 Emergency Response Phone 4 Manifest Tracking Number fl � - WASTE MANIFEST 2+. . '``. ff ? ;�-.:._ .'; v til . . :mJJ K i Generators Name and Mailing Address Generators Site Address{if different than mailing address) Generators Phoneme`- 6,Transporter 1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address i t, Cs:lfry s: U.S.EPA 1D Number 95 Fac€lily's Phone: g� 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, u.. 10.Containers 11,Total 12.Unit HM and PackingGroupif an 4." Quantity Wt.Noi. 13.Waste Codes 1. frAp 3 KKt Z 2, LU Ur 3. mow... _. 4. Special Handling instructions and Additional Information Jas 16, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents oft (s consignment are fully and accurately described above by the proper shipping name,and are classified,.packaged, marked and iabeledlplacdrded,and are In all respects in proper condition for transport according to applicable international and 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFA 262,27(a)(if I am a large quantity generator)or(b)(ifl,am a small quantity generator)is true. GeneratoeslOfferor's PrintedlTyped Name Siggat re Month Day Year � r.. -1 16.lntornational Shipments i- ❑Import to U.S, ❑Export from U.S. Port of entrylexit: ? Transporter signature(far exports only): Date leaving U.S.: 17.TransporterAcknowledgmant of Redeipt of Materials LQ Transporter 1 PrintedlTyped Nam�e,� Signature � � � Month Day Year V , '& v ,&.^t.F g d:. z Transporter 2 PrintedlTyped Name 1. - f Signature Month Day Year Ice Y' 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residuej j ❑Partial Reaction Full Rejection Manifest Reference Number: F� 18b,Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: LL, 18c.Signature of Alternate Facility(or Generator) Month bay Year Q Z L" Hazardous Waste Report Management Method Codes(l.e„codes for hazardous waste treatment,disposal,and recycling systems) d-r ri 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Meme f Signatures F t Month Day Year �� f 1 y if'rs'£ •`Y' �€ /K tl�l/"� -rrf �y5,��i'�'r �'', i,•"L' .^�,�. a;'fes' - EPA Form 87D0-22(Rev./3-05) Previous editions are obsolete, 1,; DESIGNATED FACUTYTO GENERATOR „