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0 0 7 0 4 0 2 8 2 8 KS <br /> Please print or type. Form Approved.OMB No.2050-0039: <br /> F_ lit Number <br /> 1.Generator ID Number 2.Page lof 3.Emergencyesp.onsePhq7� 4 <br /> UNIFORMManifest Tr <br /> HAZARDOUS <br /> WASTE MANIFEST 10 0 7 Oac 62 8 2 SKS <br /> 5.Gonerator's Name and Melling Address Generator's Site Address(if different than mailing address) <br /> TF <br /> Generatot's Phone: <br /> 6.Transporter 1 <br /> p!nyNalnp, T U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> e-Designated Fac l ty Name and Site Addiess U.S.EPA ID Number <br /> Facility's Phone: <br /> go, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> —No. Type Quantity w[JV01. <br /> LU <br /> Z 2, <br /> Uj <br /> 3 <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> 15. GENERATOR'SIOPFEROR'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, <br /> marked and labeledoacarded,and are in all respects in proper condition for fransporl according to applicable intemationaland national governmental regulations.it 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 certify that the waste minimization statement idengied in 40 CFR 262.27(a)(if I am a large quantity generator or(b)(if I am a small quantity genet tie. <br /> PerMnAf-P')Ifferor's Printe(Y14ked Name ignalure Month Day Year <br /> tv <br /> 'fo-77 Ononal Shlpmenl� <br /> _j n ern <br /> 1— 1-1 Import to U.S. EJ Export from Port of entrYlexit: <br /> ? Transporter signature(for exports only): Date leaving U.S. <br /> IX 17.Transporter Acknowledgment of Receipt of Mater <br /> Uj Trans'pNer I Pdntq/T <br /> pel N Month Day Year <br /> 7 <br /> let <br /> z-�-Trfsporler2 Printed _ =6 a Month Day Year <br /> i18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity 0 Type r_1 Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number-, <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> <L Facility's Phone: <br /> L <br /> fi� 1 Bc.Signature of Alternate Fadlity(or Generator) <br /> Uj Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1.UJI <br /> 2. 3. 4. <br /> i:w <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> 1-nmeal i yped Name Signature Month --Day year <br /> EPA form 8700-22(Rev.12-17) Previous editions are obsolete, DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />