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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 d.Manifest Tracking Number WASTE MANIFEST VES 5.Oenerator's Name and Mailing Address Generators Site Address(if different than mailing address) VES a]L'ortilill t"A "If1, Generator's Phone: 6 Transporter 1 Company Name U.S.EPA ID Number 7,Transporter 2 Company Name U.S.EPA ID Number 8 Designated Facility Name and Site Address Voll U.S.EPA ID Number Facility's Phone- 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conlainerg 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. O �7kT'17.f1" , u.r x 2 LU 0 3. 4. 14.Special Handling Instructions and Additional Information hit'W-1r ' 4��ti F�=iS4� �+�2]1 -I. y :-fit uli�apt�'tiier!��ss+�r�e�,.-.... ,, , .';.�•: 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 classifled,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and rational 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. GeneratorslOfferor's Printed/Typed Name Signature Month Day Year 16.International Shipments il�- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Z Transporter signature(far exporls only): Oate leaving U.S.: IX LU 17.Transporter Acknowledgment of Receipt of Materials � Transporter 1 PnntedlTyped Name Signature Month Day Year O a - Z Transporter 2 PrintedlTyped Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space El Quantity 1-1 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: I Ob.Alternate Facility{or Generator) US-EPA ID Number U LL. Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 19.Hazardous Waste Report Management Method Codes l e..Codes for hazardous waste treatment,disposal,and ree cin systems) u^ pu 9 { � Y 9 Y ) 2. 3. 4 20.Designated Facility Owner or Operator:Certification of receipt of hazardous matenes covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 6700•-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY