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I Please print or type. f=arm Approved,OMB No,20500039 <br /> I UNIFORM HAZARDOUS t•Generator ID Number 2.Page 1 of3.Emergency Response Phone rOO1794185 <br /> Manifest Tracking Number <br /> WASTE MANIFEST VES <br /> 5.Generators Name and MailingAddress Y(IMAMY.Vu111V Generators SiteAddress(ifdifferentthanmailingaddress) <br /> FED EX CIRCRiI1iD 3/1M <br /> sol i w WAY <br /> MnGenerators Phone: <br /> 6.Transporter 1 Company Name VS,EPA ID Number <br /> VBQUA 115 79CM4VAL90WMNS AT J. D 0 a 0 6 3 1 3 6 9 <br /> 7.Frf0porter 2 qny N J� U.S.�P ID umbar <br /> B.Designated Fadlity Nam and Site Address 1 U.S.EEPA W Number <br /> VSUME8719CHRICALSOUT[NM <br /> 760 HKIRWAY 73 <br /> Fadli s Phone: T X D 0 0 0 B 3 B 9 9 6 <br /> ga 9L U.S.DOT Description(Including Proper ShlWng Narne,Hazard Class,ID Number, 10.Conlalnom 11.76101 12,Unit <br /> HM and PaWdng Group(f any)) Quanti 1 a.Waste Codes <br /> No. Typo ty wivol. <br /> O 1 NtJM"AHATARDM WASTE LNQT^0A.=PAM, 2 D•M 302 P OUM <br /> M <br /> 2. I <br /> w <br /> s. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information RR 5@r4ir4CWMWW by <br /> 11It OR rl lmnapatEtlr M add iRt t11rt11w#11tgo tAoipOill�s tDe 61IIWL l W.11 M9& <br /> + <br /> 15. GENERATOR'SIOPFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately desodbed above byth¢proper shipping name,and are classified,packaged, <br /> marked and labeiedlpiecarded,and are in all respects In properoondidon for transport according to applicable inlema8analand national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that Bta contents of this corlslgnmant conform to the terms of the attached EPAAcknowledgmeni of Consent. <br /> I ceft that the waste minimization statement identified In 40 CFR 262.27(a)(N 1 am a large quantity generator)or(b)(it I am a smati quantiiy generator)is true. <br /> Generator DfiemrsNniedffypedName Sign r Month Day Year <br /> G <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pert of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Priniedlfypad Name Signature Month Day Year <br /> a JIt 11 0'12 1 <br /> Tran rter 2 Pri edlT d Nam Signature Month ay Year <br /> 1B.Discrepancy <br /> 18a.Discrepancylndloaticn Space <br /> ❑ quantity ❑Typo ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 184.Altemote Facility(or Generator) U.S.EPA ID Number <br /> � f <br /> U <br /> W Fadlily's Phone: <br /> w 180.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Haz@rdous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) I <br /> G 1. 2. 3. d. { <br /> 20.ffesignated Facility Owner or0per r.Certifrcallon of receipt 81 hazardous materials covered by the merit 6cept as noted M Item 16 <br /> ' atu ear <br /> r <br /> EPA Form 8700.22(Rev.12.17) Prem editions are clsolete. DE G ATI*R ACII,ITY TO EPA's e-MANIFEST SYSTEM <br />