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Please print or type, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11.GerkeratorlDNumbe' 2.Page i of 1 3.Emergency Response Phone 4.Vanlfest Tracking Number <br /> WASTE MANIFEST G A L U 0 0 4 2 4 8 1 7 1 ?,U0 fJZ -91 uv 020351075 _ J�{ <br /> 5.GaneWoa Ian*�r�d f��ling f�dc�,� r, • r Ali t N fill;f 11 oto s SiteAddres5('�d�ifferent than mad? address) y �■ <br /> uua c1�+ llrrr ar'x r re�j�r'.T U14E rri� 08 EMININ"i i14:11Gi-i 1 U111—li4U. <br /> '+ G�{r Dow;ac)14 vRt Gol OAF-ICY W"F;d'rWf <br /> T-'; F- Ir`C 2—t 3M Lr 1 IRAQ? CA SS= <br /> Generator's Phone: 1 J 0 6 2 2 5 7 6 0 <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> F'�h itA Lnvlrumnentaf----;elvices G A U D b 3 is b Ei f to 4 <br /> t <br /> 7.Transporter 2 Company Name U.S.EPA 1D Number <br /> f..Des'Hated Facility Name and S dress U.S.EPA 10 Number <br /> `E Wf1Fa rs r , uv�� ury <br /> LLJP4U biz/A`: t ua rib I i <br /> FacnliVs.Phone: 6W 8121i-67219 G A D l7 2 O 4 Q O u 1 9 <br /> 9a. Sb,US,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit i3.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity VVIL/vot. <br /> a 1-u1�1 7 , u" ESTE t:l I., t�r�l r Cl ►e� '' <br /> a — <br /> ex <br /> W <br /> � z- <br /> LU <br /> 3. <br /> a <br /> 14-S peaat Handlau�Instructions and Additional Information V �3Ls 1 i t1-t <br /> t.l„11 k r:;_l:-t•:i'. P�'r ,r:_ k. !IdETICi.)r,l-tI-A-1 !r', , <br /> r 1 <br /> .i 1_ � <br /> K. <br /> 15- GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accuralely described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeled'placarded.and are in ail respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cpnsignmeni conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generamr)or(b)(if I am a small quantity generator)is true. <br /> GeneraWslOf{eroes Pdn dfiyped Name Signature + f f Day Ye <br /> 16.International Shipments <br /> ❑Importto U.S. ❑Export from U.S. Port of entrylexit <br /> ? Transporter signature Ifor exports only): Date leaving U.S.: <br /> W ura <br /> 17.TransporterAdwledgment of Receipt of Materials <br /> i <br /> Transporter 1 PrintedlTyped Name 0 < SignatureDa Y <br /> Y ii <br /> �. [- ( " { -;-` L I <br /> W Transporter 2 Prtnt Vyped Name signature Month Day Year- <br /> 19. <br /> ear1B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ puanti ❑partial Rejection <br /> ty Type Residue i ❑Full Rejection <br /> Manifest Reference Number. <br /> H 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> U <br /> ;� Facitity's Phone <br /> C3 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> 4 <br /> uJi <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste lrealment,disposal,and recycling systems) <br /> LU t. 2. 3. 4, <br /> 20-Desgnated Facility Cwner or Operator.Certification of receipt of hazardous materials covered by the manifest except as toted in Item 18a <br /> Printed7yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />