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RECEIVED 3/25/2019 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORHI HAVMDOU5 t Generator iD Number 2.Page 1 of 3.Emergency Response Phone [fast Tracking Number <br /> WASTE MANIFEST 4.ManSKS <br /> 5.Generators Name and Mailing Address Generator's SitalAddress(If different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EFA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> Faci'ity's Phone, <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity wl.NaL 13.Waste Codes <br /> t' '.:" }�' 4 4A1Za�[tf`s?t.b 6,1P <br /> ' AX71�` ..1'J AR'A'V l� _�...}._r4 PY('i;' ..,._ <br /> 2. <br /> LU ( <br /> 3. <br /> 4. <br /> 14 Special Handling lnstmdlons and Additional Information <br /> 15 GENERATOR'8lOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,eb are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationalamd 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 EPAAcknowledgment of Consent. <br /> I cerbfy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quaridty generator)or(b}(iFf am a small quantity generator)Is true, <br /> GeneretorslOHerars Prinledfryped Name Signature Month Day Year <br /> F 16.international Shipments <br /> Z ❑Impod to U.S. ❑Export koro U.S. Port of antrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> � 17 Transporter Acknowledgment of Receipt of Materials <br /> L2 Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> a <br /> C0 <br /> Traispoirter 2 Pr nted yped Name Signature Month Day Year <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type L1 Residue ❑Partial RefectionnFull <br /> Manifest Reference Number; <br /> 18h.Alternate Facility{or Generator} U.S.EPA ID Number <br /> J <br /> U <br /> +a Facility's Phone: <br /> w 18c,Signature otAllernale Facility(or Generator) Month Day Year <br /> a <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems( <br /> p 1 2. 3. <br /> 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 /> PriitedlTypetl Nama Signature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />