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<br />Form Approved. OMB No. 2050-0039 GENERATOR UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number 1-J,1„
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<br />2. Page lot
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<br />3. Ethergency Response Phone
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<br />4. Manifest Tracking Number
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<br />5. Generator's Name and Malting Address Generator's Site Address (if different thgn mailing address) .
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<br />Generator's Phone: I.- viCfriA//47/4", it/0 .c3'T 1. -1,C1_9 -5-717/7 I &A 7/lit0r i Al6 95-33o
<br />Transporter 1 Company Narfte U.S. EPA ID Number
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<br />Transporter 2 Company Name U.S. EPA ID Number
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<br />Designated:Facility Name andelte Address
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<br />U.S. EPA ID Number
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<br />Facilltys Phone: 55 q ‘ 3gc, -.40-irrat 9 I), I
<br />ga. Sb. U.S. DOT Description (inducbig Proper Shipping Name, Hazard Class, ID Number, 10. Containers it Total 12. Unit 13. Waste Codes mi and Packing Group (if any)) No. Tyne Quantity WIA/ol.
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<br />14, Special Handling Instructions and Additional Information
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<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 pruper condition for transport according to applicable international and national governmental regulations. If export shipment and I sin the PritT,Ty
<br />Exporteni certify that the contents- of this consignment donfonnto the teimitf the attached-EPA Admowledgment 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 ' am a small quantity generator) is true.
<br />Ge s/Offeroes Printed/Typed)gme Sip Month Day Year
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<br />16. International S ' ants r1 r-i
<br />Import to U.S. LjExportfromU.S.-- ' -• - Port of entry/exit.
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />F.5 17. Transporter Acknowledgment of Receipt of Materials TRANSPORTE Transporter 1 Printed/Typed Name ggnature Month Day Year
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<br />Transporter 2 Printed/Typed Name Signature Wirth Day Year
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<br />' I I I DESIGNATED FACILITY -÷ I 18. Discrepancy
<br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection
<br />Manifest Reference Number.
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Da:,. Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1. 2. 3. 4.
<br />20. Designated Designated Facility Owner or Operator: Certification of receipt of tozardous materials covered by the rhanifeat except as nded in Item 18a •
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<br />Month D.;-ii, Year Prin Name Sig lure upkv. 1*ii:L........._ ... _
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<br />EPA Form 8700-22 (Rev. 12-17) Previous editions arp obsolete.
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