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<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />I. Generxor ID Nt,mber
<br />' R_C) c i • 4 4 80.
<br />2, Page 1 of 3. Emergency Response Phone
<br />i:cu-) 55 (:, (-
<br />4. Manifest Tracking Number
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<br />5 Generator's Name and Mailing Address ...) . k . 1 ,...i r I, t_ 00 6,1.20‘ni ( Generator's Site Address (if different than mailing address)
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<br />Generator's Phone: 0 0- erL.3 kixiekr( L.) log Li ri, A.Ts-sI
<br />Transporter 1 Company Name U.S EPA ID Number
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<br />Transporter 2 Company Name U.S. EPA ID Number
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<br />F, Designated Facility Name and Site Address ,..,L J.0a sl A ' - U.S. EPA ID Number 1'1'6110,5X al .91--P-t-s- KE44-14, ten ck..h
<br />i 7 P Ric], K4P+1- it /71 0 6 64 cle— 44-v41— Y ( '
<br />Facility's Phone: ( r35 tit) '3 iits -4-1i 1 C:13071Z: I t.) ,/- t.. "
<br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. 10. Containers it Total 12. Uni 13. Waste codes HM and Packing Group litany)) No. Type Quantity Wt.,,Val.
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<br />14. Special Handing Instructions and Additional Information '1.7r. :1 '..r....:- -
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<br />IS. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this convnent are fully and accurately described above by the proper shipping name, and are classified. packaged
<br />marked and labeled/placarded, arid am 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 contorts 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 tarn a large quantity generatdiroM)1IF a small quantity generator) is true.
<br />Genet /0fferor's Printed/Typed 7/ Month Day Year ...
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<br />16. International Shipmerlis
<br />Import to U.S. LlEaportfromU.S. Port of entry/ext
<br />Transporter signature (for exports only): Date leaving U.S.: , TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed Name Signal Month Day Year _ ° ......
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<br />Transocrter 2 Printed/Typed Name , .,5igriature Month Day Year
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<br /> I I I I ' DESIGNATED FACILITY --* 1 18. Discrepancy
<br />Discrepancy Indication Space Quantity Type Residue LIIIPartial Refection Fu N Re-motion
<br />Manifest Reference Number
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facilly's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />2. 3. 4.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as rated in Item 18a
<br />Printed/Typed Name ,. ' • Signature Month Day Year
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<br />Form Approved. OMB No. 2050-0039
<br />DESIGNATED FACILITY TO GENERATOR EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.
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