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Please print or type. Fcxm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generates ID Number 2.Page 1 of 3.Emergency Response Plane ranifest Tracking Numirar <br /> WASTE MANIFEST (j�- ` �g gt "��� —� 019703569 JJ K <br /> 5.Genera Na and ai'ngp�,�es Generata's,Sdte Add ss(if [(ere ani ddress) <br /> �Mn f o,� ,� lel►�raeld cue G li O N��aA ti�alc+ c ►t�' i <br /> /k�4n'• (Y1oni�ts'r �eceiv�h <br /> 733 'G- U-► h-m 5} <br /> e�5�-Zo ea,.Pv✓w�-e� OrP r2 s��¢-At4 1,�b °I SZob <br /> 6.Transporter 1 Ccmpany Name U.S.EPA ID Nutirher <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Dei a F cility f�gLng an S' P U.S.EPA ID Number <br /> y� �vr�ra'Yl1 S'S'Y�4J�"' <br /> 1 <br /> Cit ct 3 <br /> FaciSty', na: (5-62�) 93A -S''1`'�S" C A O d a8`-t d oI d 104 <br /> ga 9b.U.S.GOT Description(inc!uduig Proper Shipping Name,Hazard Class,ID Number, 10.Contairx rs 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Grcvjp(if any)) No. Type Quantity Wt.Nol. <br /> 0 1 3`i3 <br /> NiS--i <br /> A VMS CovnVbR. L�'�u�d,N.o.S. cstl� 4 oil 3gS v <br /> W <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14�$p IpNa i�I,r s frSrr�ar Additional forn tior+4 <br /> JPS 1t49,6q 7 J <br /> WV- V�7 ;U4� <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and arcuratefy described above by the proper shipping name,and are classified,packaged, <br /> marked and labOad/placaded,and are in all respects in proper cond+tion fa 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 ccoform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified'm 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a smat quantity generator)is true. <br /> Generator's/Offeror',Prinied/T ped Ne Signator Month Day Year <br /> "ear <br /> 1 Qj tenrational Shipments <br /> F ❑Import€o U.S. El Export from U.S. Port of entry/exit: <br /> z Transporter svgnature(for exports oNy): Date leaving U.S.: <br /> of 17.Transporter Acknarvledgment of Receipt of Materials <br /> H Trans er 1 P^rinted/Typed Naps, Signature Month JDay— Year <br /> CL <br /> I �R <br /> Z Transporter 2 PrintedlTyped Name Sagnatuve Month Day Year <br /> 9 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp 1 <br /> ElT e Residue ❑Partiel Re ection El Full Rejection <br /> Mani€est Reference Number: <br /> H 18b.Alternate Facility(or Gererator) U.S.EPA ID Number <br /> _J <br /> V <br /> u- Facility's Phone: <br /> w 18c.Signature of Alternate Facility(cc Ger-rator) Month Day Year <br /> d <br /> Z <br /> N19.Hazardous Waste Repot Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> q 1 �-Q <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous aterials covered by the manifest except as noted in Item 18a <br /> Printed/Typed acme /�� Signature M nth Da „Y� <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's 2-MANIFEST SYSTEM <br />