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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator iD Number 2.Page 1 of 3 Emergency Response Phone A.Man4fest Trackin Number WASTE MANIFEST 014 03433 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Ll "EA Generator's Phone: 6.Transporter I Company Name U,S EPA ID Number -- 7.Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address U.S.EPA ID Number wv,4 ZI Facility's Phone 93. 9L U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 waste Codes HM and Packing Group(if any)) No. Type Quantity wt."Voi. 0 ............. LU LU 2. W .... ....... ....... 3 4. j 14,Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of anis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and la beledilp;acarded,and are in 311 respects in proper condition for transport according to applicable internatlonal and national governmental regulations,If export shipment and I am!he Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262 27(a)(if I am a large quantity generator)or(h)(if 1 am a small quantity generator)is true. rsiOfferor's,l t�pffyped Name re 1,11 1 o0h Day Z4 21,Ye I1 a,r ❑ �17 Import to U.S. ❑Export fro j U S. " Port;of ,nlry*it:: Transporter signa!ure(for exports oriiy): Date avirljua: 17,Transporter Acknowledgment of li of Materials 7 7 Transporter I Printed.iTypod Name gnalure Month Day Year 0 CL V) Z Transporter 2 PrintedfTyp ed Name ure Month Day Year < Ile Discrepancy 1 Sa.Discrepancy lndica.:on Space ❑ Cuantity ❑Type ❑Residue ❑Partial Rejection Full ii Manifest Reference Number: 18L Alternate Facility(or Generator) U.S.EPA 1D Number L) LL Facility's Phone: LU Morth Day Year 18C Signature of Facility(or Generator) Z Fn P 19.Hazardous Waste Report Management Method Codes{i.e.,codes for hazardous waste treatment,disposal and recycling systems) LU 1 2. 20.Designated Facility owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Sa PrintediTyped Name Signature Monti- Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete.