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VIA <br /> Is <br /> Form Approved. OMB No. 2050-0039 <br /> Please print or type. 4. Manifest Tracking Number <br /> 1 Generator ID Number 2. Page 1 of 3 Emergency Response Phone KS <br /> UNIFORM HAZARDOUS 1 . E ! I :r', I . ' 'y " ' . 1, t 1?? . s r , ,. , . ). r r r` ) ,� a <br /> WASTE MANIFEST Generator s Site Address (if different than mailing address) <br /> 5. Generators Name and Mailing Address r r r I <br /> ._ _ <br /> r <br /> Its <br /> IA <br /> Generators Phone: { it <br /> U.S. EPA ID Number41 <br /> 6 Trans otter 1 Com any NameVi <br /> tt <br /> U.S. EPA ID Number <br /> 1 <br /> 7 Transporter 2 Company Name { t ' t <br /> 14 - 1 ° U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address <br /> € Ihi <br /> I- <br /> ., , <br /> it <br /> Fadlitys Phone: 10. Containers 11 . Total 12. Unit <br /> 13. Waste Codes <br /> 9a 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, No Type Quantity Wt.Nol. <br /> HM and Packing Group (d any)) <br /> WIN VIEW <br /> 1 . If s > � tY ) t. { t t ai.) tl ) t�je <br /> O 4_ l . : Y i_., 1 l , t 11 Is I <br /> ?::, <br /> Z 2• <br /> u.t <br /> 3. <br /> 4. <br /> 11 OEM MEN 111 11 <br /> 14, Special Handling Instructions and Additional Information -t- t I t ± j !. ' _d ;i <br /> VJ €; r :"r ("-4 ° { <br /> 4p k -1tet . 3 U t ? z t t c_E t e � xyr t t { {, n s ; a yP t ittos1i <br /> It f o !'t� t :. i f . Vr - .v } ; t t <br /> . . li'. ? : t - t it «2S �: ' ' - . te . 4 , -+ r < o , . ' } } '. 7: 5 �'. t ; 't` &-` ..—a - 9 � ,' ttF . . , f - : : rz < " it ?"a : E ' er. , ) is idtt::a „>+ 'S' t'ltns < i� drttF31 _ <br /> 15. GENE RATOR'SIOFFEROR'SCERTlFICATION: ( 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 intemational 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 EPA Acknowledgment of Consent. <br /> 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. Month Day Year <br /> III WIN ISignature I Ir IV <br /> Generators/Offeroes Printed/ I yped Name f <br /> r <br /> � <br /> `' ¢ <br /> ” ' 1 F <br /> J16. International Shipments Y Import to U.S. ❑ Export from U.S. Port of entry/exit <br /> ZDate leaving U.S.: <br /> Transporter signature (for exports only):WEI <br /> t + <br /> W 17, Transporter Acknowledgment of Receipt of Materials l Month Day Year <br /> Uj Transporter 1 Printedfryped Name Signature r <br /> u <br /> CL _ W Month Day Y ear <br /> zSignature <br /> Transporter 2 PrintedtTyped Name <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 /> J_ <br /> V <br /> ii Facilitys Phone: Month Day Year <br /> w 18c. Signature of Alternate Facility (or Generator) <br /> a <br /> z <br /> N19. Hazardous Waste Report Management Method Codes (Lel, codes for hazardous waste treatment, disposal, and recycling systems) <br /> NIMBI2 <br /> 3. 4. <br /> . <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br /> Printedrfyped Name Signature <br /> EPA Form 8700-22 (Rev_ 12-17) Previous editions are obsolete. EROR' INITIAL COP <br />