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Please print or type. Form Approved . OMB No. 2050-0039 <br /> 1 . Generator ID Number 2, Page 1 of 3 Emergyency Response Phone 4. Manifest Tracking Number <br /> enera <br /> UNIFORM HAZARDOUS . °t' t Ir t?! cc t "fj:) ( j, — !lt i : : i t t t, t <br /> WASTE MANIFEST ¢r [.. - ,; 9 A <br /> SKS <br /> 5. Generators Name and Mailing Address q r Generator's Site Address (if different than mailing address) <br /> ). t i fI FP . �r i. ' 4 , 14, ! <br /> Ir ZI42 <br /> L'it All <br /> All Am <br /> Generator's Phone: All <br /> 6 Transporter 1 Company Name U.S. EPA ID Number <br /> AAA 7 Transporter 2 Company Name U.S. EPA ID Number <br /> r £ rt } rrt" t ' t r" r Y� .Pr4rr t ' tid a c: f•mt <br /> ..{. . $`. . t , •{ s , C+ .TT. I1C � F5. _ . �r � 4 . _. .. . { - Is�t� . ,x . ..: .lev�..• n <br /> 8. Designated Facility Facili Name and Site Address . . r j ; U .S. EPA ID Number <br /> 7 # ! r <br /> Facililys Phone: <br /> 9a, 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Tota{ 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br /> Ofr (17` ( {, 13. i2 : 6. $ d _.t / ( Kill, <br /> . . , f .. . . . ., s_. ...� <br /> 2. <br /> Ill <br /> 3. <br /> 4. <br /> 14. Special Handling In and Additional Information ; r P r ,; c' f <br /> � , �i Ti .- t �• . l G S3kt Q ! i - v :s Sa t� C , <br /> iit: t: [ —. If41 <br /> 1 <br /> 15. GENERATOR'S/OFFEROR'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 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 <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> AMARA <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> e <br /> S <br /> 16, International Shipments ❑ Export from U.S. Port of entry/exit: <br /> F— Elimport to U.S. P <br /> 2 Transporter signature (for exports only): Date leaving U.S.: <br /> rY 17. TmnsporterAcknowledgment of Receipt of Materials <br /> LLJ Month Da Year <br /> [ — <br /> Transporter 1PriptedfTypedNameAll <br /> Own 11 <br /> Signature Y <br /> 0 f <br /> _co _. Month Da Year <br /> Transporter 2 Pdntedrfyped Name Signature Y <br /> F <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> r 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> rai Facilitys Phone: Month Day Year <br /> LU 18c. Signature of Alternate Facility (or Generator) <br /> a <br /> 0 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 21 <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR ' S INITIAL COPY <br /> ..r k'.rt ' .. _ (� 14t rpjs � <br />