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Please print or type. Form Approved.OMB No 2050-0039 UNIFORM HAZARDOUS 7or ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST ;U.L j j;� i VES 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) VJ)Eh Y,id1ii Generators Phone, 6 Transporter 1 Company Name U.S-EPA ii]Number � h 7.Transporter 2 Company Name U.S.EPA ID Number 4 4) U 4 o Z i 7 4 7 8.Designated Facility Name and Site Address .rA ES TBC / ..Wu7}K& U 5.EPA ID Number w; C. 1 704 W"IUST STRM Facility's Phone: Q6 33,11 X. AMA.CA 41M l 4 E3 O U 4 3 0 2 C A 3 T 98. 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)) Na Type Quantity W1.N01. f - t'-_i. 0O ! }1 I I Q i CL' � W LU 3. (VVA%ill eLZK.3XWJ-%MAf.tfA,c3i 1V,1.7.d 4. 14.Special handling Instructions and Additional Information , altlF r&jg j� W add PWCk1�J81 A Al /! 15- GENERATOR'81OFFEROR'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)(lit I am a large quantity generator)or(b)(if I am a small quantity generator)is true - Generator'slOfferor's Printed/Typed Name Signature Month Day Year 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 Acknowledgment of Receipt of Materials Transggrtet'1 PrintedlTyped Name Signature Month Day Year O a , Z Transporter 2 PrintedlTyped Name Signature Month Day Year a H 18.Discrepancy 18a.Discrepancy Indication Space El {quantity ❑Type ❑Residue L-1 Partial Rejection ❑FuEI Rejection Manifest Reference Number: 186.Alternate Facility(or Generator) U.S.EPA ID Number J U ua Facility's Phone, 18c.Signature of Altemate Facility(or Generator) Month Day Year a z 0 N 19.Hazardous Waste Report Management Method Codes(i.e-,codes for hazardous waste treatment,disposal,and recycling systems) LU 0 1- 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a 7yped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY