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RECEIVED 11/18/2021 VIA EMAIL Pr5G I.1/J2l2/ Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST FLE 5,Generator's Name and Mailing Address Genefalors Site Address(if different than mailing address) iii} V10(4 I iLr„i.} Generators Phone: r T 6.Transporter 1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number I'1I��(l3tJl..l i(f1Ei� ( it, Facility's Phone; 9a. 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 Ouandly WWol. L . Z 2. uj 0 4. 1 14.Special Handling Instructions and Additional InfofmaUon torr¢ora fdl sl,}��i h)-`l 5f I-V).3 et'e'st)I AF- 15. 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 Iabeledfplacarded,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 o(Us consignment conform to the terms of the attached EPAAcknowtedgment of Consent. I cerlify that ft waste min€mizatton slatement 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. Generalors101ferors PdnledlTyped Name Signature Month Day Year a 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only):. Date leaving U.S.: w 17.Transporter Acknovitedgment of Receipt of Materials LLI Transporter i PdntedlTyped Name Signature Month Day Year 0 a ri 2 Printedfryped Name Signature Month Day Year 19 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑T ❑ ype Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternalo Facility(or Generator) U.S.EPA ID Number 0 Facility's Phone: W 18c.Signature ofAlternateFacility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3, 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materiats covered by the manifest except as nded in Item 1 Be PrintedrTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY