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06 / 11 / 2021 1 : 46 PH FAX 2099488625 AHCE SAW [a] 0001 / 0007
<br /> 614ase pri:,, ur type. pill Form Approved, OMB No. 20S0o0039
<br /> UNIFOfiM Wal ARCfOUS 1 Ganvtator ID Number ?.. Page i of 3 , EmurgCncy Response Phone 4. Monifest freaking Number (�
<br /> WASTE MM 11PEST :> ' `-" B
<br /> 111 S Genrrator s P' ame and MOUIng Address Generelor s Site Address (if dilfaron( 1110n ma ling address)
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<br /> Geeorn(or's Phone:; , '., ,. �: : ; ; ,. ' .9 :; i , ?
<br /> 8. Transporter '• Cv mmny Name U$, EPA ID Number
<br /> 7, transporter 2 Company Name U.S. EPA ID Number
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<br /> 6. Dooi£inlled ReClllty Name and Site Address U .S. EPA ID Number
<br /> 4111 1 o,L 1. , '
<br /> Facility s Phone;: "S ' ' : : 15. .
<br /> ga 9b, UA, 1301' t)Psrription (including Proper Shipping Name, Hazard Chw�. IC Nundk:f, 10. Containers 1i . Total d12, Unit
<br /> and Padding Group If an No. Type (lure+ore ty Wt,NoL 19 , Waste Cates
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<br /> 14, $peCmi Handling InRtmctiona and Additional Information
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<br /> 15. GENERATOR'SIOFFEROR'$ CERTIFICATION: I hereby declare that the rnntanta of this f:nnaignmenl are fully ant omirotely described abeve, by [lie proper shipping name, ird Oro dossilial, packaged,
<br /> marked and labelediplacarded, 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 /> Rxpor(er, I e(vtily that the conleoto of this rx}ns gnmPot ronfornl tr the tonna of the attar,.hed I-Nn AcxnMNPd6nt enl of 1 lnseni . / ' Id
<br /> I cer6ly that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I sm a small quanlityWill .generator),ia true.
<br /> j Gpipr1tofsIC7fferrPRPAnledfIype,dNaniq ; ,,_ ..,. ,• Signature Month Day Year
<br /> 1 ,
<br /> tFinational '
<br /> ,op 16• InShipments
<br /> F Import to U.S. Export from U.S. pofI of onlryfexit•
<br /> Transporter signahue (for exports only): Data leaving U .S.:
<br /> I W 17. TransporterAcknowlcdgnwn( urRowiptofMaloduls
<br /> Lip I Tranaporter ] ' PrtnteflFlypad lip I " , . I ' / Signtrlmc " Month Day Year
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<br /> Tranaporfe,0 PRntedflypad Name Signature Morellirp Y6ur
<br /> 18. DNorepanry
<br /> 18a, Discrapanoy Indication Space I Quantity i ITypa I I Residue ❑ Pailful Roi;:clion ❑ Full Rejection
<br /> Manifest Reference Number:
<br /> I Bb. Alternate Facility (or Generator) U S. t1i Ip Number
<br /> U
<br /> Facility's Phone:
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<br /> 18c. Signature of Aitcrnalc Facility (or Gcnurator) Month pay Yea
<br /> 2
<br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, dlspoplal, and reGyCii11l1 ;:ystvms)
<br /> 1 , I. 3, 4•
<br /> 20. Designated Facility Ovmer or Operator: Cerlificalion of receipt of hazardous materials rnvered by the manifest except as noted in Ilem 18a
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<br /> Nnniednyped Name Signature Month Gay Year
<br /> EPA Fori118700 .22 (ri it 2. 17) Previous oditidns aro obsolete.
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