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Please print or type. Form Approved.DMB No.2050-0039 <br /> -UNIFORM HATARmus 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracklag Number <br /> WASTE MANIFEST ;r+,...t.dtik(:3(ti:�f3 7 tt[#f'r+if4 .;:; 1JJK <br /> 3.Generators Name and Marling Addrnp f :f r 3 ;! �' GeneraWs SM Address[f diferentthan making address) <br /> �3_r�reT•r+,F.l C'4,e r^s of.�hip <br /> .t;ril'S L mat.{iortd *ash fin±re EsxJ <br /> h;efx�xrs+lt�, 1 Fa 3ex3ii!9 tJti f �.Pfxxln �--A 14K k #} t t q <br /> Generator's Phone-` ='­474 <br /> B.Transporter 1 Company Name - U-S.EPA ID Number <br /> 7.Transporter 2 CAmpany Name U.S.EPA ID Number <br /> 8,Designated Facility Name and SHGAddrass U.S,EPA ID Number <br /> - <br /> Facility's Phone; <br /> 9a- 9b•UZ DOT Demiption(including Proper Shipping Name,Hazard Class,ID Number, 1D-Containers 11-Total 12.Unit <br /> HM and Packing Group Cd arry)} No. Type Quantity Wt.Nol, 13.Waste Codes <br /> 1'I f ht 4 "i lifpq prr+: hh�m►1nll�s iH!!9e°n.itri, 1 x.50+,'7 }14 <br /> �a3.`r". !'i .iav'a.'zv-n{i'�L• if'�f{f"- i28 r.,y '- <br /> 2. <br /> NJ <br /> Y7 <br /> 3- <br /> 4. <br /> 'ASdll111M. ons and Additional Information <br /> r� pfI IE, <br /> ►'44lriiPriatc!uvivw to'g"-Oil <br /> 15. GEN ERATOR'WFFEROR'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 labeledfplacarded,and are in all.respects in proper cpndtion for transport according to applicable in€emationaland national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certfy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cerfify that the waste minimization statement iderhiifred in 40 CFR 282.27(a)(if f am a large quantity gerheratoj or(bj(ifI am a small quantity generator)is true: <br /> Generatoesldfferor`s Printedffyped Name Signature Month Day Year <br /> a 16.International Shipments <br /> ❑import to U.S. ❑Export free U.S. r Port of entryfexit: <br /> ? Transporter signature(for exports oniy): Date leaving U.S.: <br /> Ce Lu <br /> 17.TransporterAcknowledgmant of Receipt of Materials <br /> Transporter i Pr thted(f}rped!Name l .� } Signadlre t � Month Day Year <br /> gy <br /> Transporter 2 PrintedfTyped Name Signature V Month Day !Year <br /> i" <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ 4uantity ❑Type ❑Residue 0 Aortal R*,fi h ❑Full Reledion <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator} U.S.FPA ID Number <br /> C.1 <br /> I Facility's Phone: <br /> 1 Cc.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treabnent,disposal,and recycling systems) <br /> f- 2. 3. 4. <br /> 20.Designated Factiity Owner or Operator.Certificaton of recelpt of hazardous materials covered by the inani€est except as tided in Itam 18a <br /> r ntecdfed a ,� Signature r is z'1 _ Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, f .'' TRANSPORTER COOY <br /> .;7 <br /> r <br />