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Form Approved.OMB No.2050-0039 <br /> Please print or type. <br /> 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 14'60034546 <br /> nffest Tracking Number DAT <br /> UNIFORM HAZARDOUS 7 <br /> WASTE MANIFEST ' <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> t L� <br /> v 6° r �r �t5'T7 <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address RAN, <br /> (� ` U.S.EPA ID Number <br /> A`.3� L ri 1 -t{i �,fiVa Ei4 Li �9'l/Vt_ Ili PRi.'i.�i' h Lt\, r <br /> Nawlao4r, Drive US <br /> Facility's Phone <br /> 9a 9b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13,Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wt.Nol. <br /> _q7 <br /> 0C Qi3s <br /> W00 <br /> 4. <br /> ,I T, o <br /> c <br /> r14. pecial Handling Instructions and Additional Information <br /> c in(I`# ) Ilf s#{it_+3(l iLi,i A` (2) 043`t ii <br /> 116t 'i�l`��#1 #IYI'#il$HL4Ik�Tt 3) i�C%E'�E%(_(➢£Ik-ija <br /> � _ ,` rL#IvRII#f #Ilri, `5iS it ) GrISF� kiti5-I!? ERE(II) (.; T?t? BIESt?. �, fcsP f,�2 <br /> 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment 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 generator)or(b)(if I am a small quantitygenerator)is true. <br /> Generator's/Offerors Printed/Typed Na Signature Month Day Year <br /> te.� V <br /> J <br /> 116.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? <br /> Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> 10 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp er 1 Pnnted/ryped Nartte Signature Mon— Da <br /> a L- �-- <br /> Z Transporter 2 Prin a(typed Nt�me t Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J_ <br /> V <br /> tai Facility's Phone: Month Day Year <br /> W18c.Signature of Alternate Facility(or Generator) 1 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 03 <br /> 4 /21 � 41 Y-1 <br /> W 1 Z. <br /> ��� <br /> 20.Designated Faclli Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Mom pay L <br /> Printed/T tNam Signature <br /> �l/e <br /> EPAForm 8700-22(Rev.12-17) Previous editions are obs let DESIGNATED FACILi V trA's e-MANIFE T SYSTEM <br />