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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 4.Man'est1Tra in N mb r 1 I WASTE MANIFEST 5. F`E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number S aIrV 8.Designated Facility Name and Site Address: s - r f-. -ii d, U.S.EPA ID Number x095 w taiia;1Os Dr. Ea. Facility's Phone: ga 9b.U.S.DOT 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./Vol. 3'I Otic fa Z 2. ;:.760, Waste 9 Cr LU I v a ERG#154 3. t t 4. 14.Special Handling Instructions and Additional Information 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 quantity generator)is true. Gene tor's/Offeror's Printed/Typed Name pign re Month Day Year ,j Zansporter Interna iona Shipments ' ❑Import to U.S. ❑Export om U.S. PO of ent exit: ? signature(for exports only): ate leavi U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed NameSig atur Month Day Year O . Z Transporter 2 Printed/Typed lyfame A atur j-'Al J Month Day Year 1:2 51�01 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Z1 Z N 19.Hazardous Waste Report Management jMajnagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) O 1 ! 1 / �/ 2 1419- 1 3 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM -,, r 7- .rr T+,7t s a _ ,.