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,, Please print or type. Form Approved.OMB No.2050-0039 UNIFORM!HAZARDOUS � Emergency Response Phone 4.Manifest Number 1.Generator ID Number 2.Page 1 of 3.Emerenc Rus ons inac�((� WASTE MANIFEST v ;.L: , ` .- Ill I�L7 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number r ,int t't i-J 1_:LlI Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quanlity Wt.NDI. 1, LU i w a 2� 0 3, 4. i 14.Special Handling Instructions and Additional Information '} .. - . k,..r,C: .. ... . . .....v. ire,.,. _ . ._. _. ..... ."�-;.tr14 5 �-�'l: w'w'[,� Y9Fw ��' tg:'13�+>'---'Cil7' C';'{i3 aar'•� ��n�k. �ssGrtztr , 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of thie consigr ment are#ally and accurst ely descriOed above by the proper shipping name,aid are classifie ,packaged, marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable internationai and national 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. Generators/Offerors PrintedfTy ed Name Signature Month Day Year � 16.Intern clonal Ship" erns F ❑Import to U.S. ❑Export from U.S. Port of entryfexit ? Transporter signature(for exports only): Date leaving U.S.: Q� 17.Transporter Acknowledgment of Receipt of Materials � Transporter I PrintedlTyped Name Signature Month Day Year O CL U) Transporter 2 Printed/Typed Name Signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space Quantity E Type F1 Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 16b.Alternate Facility(or Generator) U.S.EPA ID Number J_ CS Facility's Phone. LU 1Be,Signature ofAltemale f=acility(or Generator) Month Day Year Z - 1 1 F019.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in tiem 183 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY