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Please print or type.M Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4.Man)ltiest,Tr&king Number WASTE MANIFEST .: :; !;. r f t •i: i s; "'s .;�.'r.J;- t,'; >`.. 1110 23 JJK 5.Generators Name and Mailing Address N . ;, }ar x s s eperatoPsSite Address(if different than mailing address) r4i:L yrs +erl i r t y4 At` Generators Phone: ;rr 6 Transporter 1 Company Name } 1 U.S.EPA ID Number C' .' D y tit t fx 8 6 4 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address +f " U.S.EPA ID Number -31 Facility's Phone ;•r; t1;:;ig i li`3 A , b r7; 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes i HM and Packing Group(if any)) No. - - Type Quantity Wt.Nol. a � 1 y,.le:ti ) .1f:�..,'v rs��.�ii-er'n,�,..:�v.;';xt�...•;:ttl+)t�.ff�ti-t.`. 'rC,Y�'t.:wtx( l,.e>;;itE r. ��-tr�.,-. . . :.. , ,..1� O F Soo Z 2. W 3 4. i f 14.Special Handling Instructions and Additional InformationI,Y, x: 15. GENERATOR'SIOFFEROR'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 intemationaland 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 EPAAcknoWedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.&7(a)(if I am a 12e quantity generator)or(b)(if I am a small quantity generator;is truet GeneratoesIO ^roes Printed/TypI Name ( e pea t. Signature - i 0 V1 e ;f q� f3 .l Month. Day Year IXA Ff A &m S A,%FA i t.tA I VA, i" 16.Inter 'national Shipments F ❑Import to U.S. ❑Export from U.S. Part of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of_MaterialsLU r TranspLorter 1 PrintedTryped Name XV Signgture I Month Day Year a Transporter 2 Prmted[Typed Name Signature Month Day Year a rr 18.Discrepancy I 18a.Discrepancy Indication Space ❑ Quantity t ty El Type ❑Residue ❑Partial Rejection ❑Full Rejection i Manifest Reference Number: H 18b.Alternate Facility(or Generator) U.S.EPA ID Number J. U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year A. a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) it 2. 3. 4. i 20.Designated Facility Owner of Operator:Certification of receipt of hazardous materials covered W the-manifest except as notedin ltem.18a PrintedlTyped Name -. ' 1y y 5 c `+ Signatures `t j Month DaY--,Ygar.. J •t, t t j}t SFJ �,' 1� A''t�`"'` ��.. (\ - `. } 'E. tt.' f/ / `7 .�✓, EPA Form 8700-22(Rev.12-17) Previous etlitidns are obsolete: TRANSPORTER COP