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i. 1 RECEIVED 4/10/2019 Pleas pe.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator rr-IIDD Number ` 2.Page 1 of .Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST t�i/liO3 —1�� 2a, I 0 0 3 7 4 0 913 G B F 5.Generator's Name and Mailing AddressP rT�sY iCi0" (!p� Generators Site Address(if different than mailing address) U�J.e3-, SSC t7�� (�� S I�1 sAti 17-L---L 1676- ST- �:C ILW 1Ss`1 G . W-L-"5c AvJ Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 0 A Q—L)Ckx�3(-�, I If L( 7,Transporter 2 Company Name r U.S.EPA ID Number G 07151 8.Designated acil ty 1amnd Site / r ' U.S.EPA ID Number G 51 -M� 644 Facility's Phone: Qi (, IV J (90 40 '� (y` E IbgjS ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 0 1 N�a.� Zc L1Az4 �� ,n,sz� Ltqul� ,, Z 33l Q rr Z 2. LU 0 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 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 EPA Acknowled ment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera r)or(b)(if I am a small quantity generator)is true. Gener tozlOffererlPrintedlTyped Name Qti c� Signal e Mor�tb � Year -J 16.International Shipments ❑Import to U.S. El Exportf1qmU.S Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials LW Tran oner 1 Printed yp d Name Si Month Day Yegar a U� Z�ir at Q Transporter 2 Printed/Typed Name Si e nth ay ye s:SG` Wa,*V- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL- Facility's Phone: UO 18c.Signature of Alternate Facility(or Generator) Month Day Year a z S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1' 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188aa Printed/TypedNa Sig ure 1Df Monih Da Year �A I l� EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)