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Please print or type, Form Approved,OMB No.2050-0039 <br /> UNIFORM KAZARDOUS 1.GJPA�' QtuT,. Z Page I of 3,Emergency Response Phone 4.Manifest Track! Number <br /> i 1 1--574?' * 2u <br /> j6�OA 0211 3914 JJK <br /> WASTE MANIFEST I <br /> 5,Generator's Name and Mailing Address Generator's Site Address(ff different than rnalllrog address) <br /> %441 f3tjF3KIrkK GDLF COURS15-i <br /> 1740 1 11COLIMNE AVE <br /> �XTMKTON,GA MU5 <br /> Generator's PhoQW610--V26 <br /> 6.Transporter I Company Nam U,S.EPA ID Number <br /> INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Addre'llAdHe U.S.EPA ID Number,., <br /> 311163 EMT PIC ID OLVD, <br /> Facillys PhondpU.'- V.a-7"Z <br /> 9a, 96.J.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10,C0111111111911 IIIJOW 12.Unit 13.Waste Codas <br /> HM and Packing Group(ti any)) No, Type Quariffly M.Nol.. <br /> rr <br /> 1, <br /> 0 <br /> Z 2, <br /> 4. <br /> 14.Special Handling Instructions and Addrtionat Information <br /> 9V1)F-'R0r-fiT# EZ RGIIIX <br /> HAXAXF!rif:�TO HE-'WAIINQf)AND U!--Ki APNOM) PF)T-. <br /> E.R. (.101MAO'll'Orv, IRMIns FDIERVIk-s <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the Koper shipping name,and are classified,packaged, <br /> marked and labded/placarded,and are In all respects in Koper corAbon for transport according to applicable Intematlonal and national goyommental regulations.It export shipment and I am the Primary <br /> Exporter,I certly that the contents of this consignment conform to the terms of the attached EPAAckro#66gn)ent of Consent. <br /> I car*that N waste minimization statement IdendW In 40 CFR 262.27(a)(If I am a large quarility,generator)or(b)(I I am a small quantity generator)is true. <br /> (39ripraWs/Offeroes Printedrryped Name Signature Month Day Year <br /> 16.Internabona]Shipments ❑import to U.S. E <br /> E '90't from U.S. Port Of entryle* - -------- <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Receipt of MaLUs <br /> UJI — <br /> 12 Transporter I Printed/Typed Nam SigneWre Month Day Year <br /> 0 <br /> Transporter 2 Printed/Typed Name Signd= Month Day Year <br /> 18.Discrepancy <br /> laa,Discrepancy Indication Space Quantity ❑Type El Residue ❑Partial Rejection ❑Full R*don <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Nurn4w <br /> Facility's Phone: <br /> 18c.Signature of Memate Facillty(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 3. <br /> 0 1 -71- <br /> Des F��ity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as rded in Item 18a <br /> Print�VN Signature Month Day Year <br /> EPA Form 8700-22(Rev.12.17) Previous eflons are obsolete. GENERATOR'S INITIAL COPY <br />