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VVAI- rtcA, A Form Approved. OMB No. 2050-0039 GENERATOR ). I UNIFORM HAZARDOUS WASTE MANIFEST 1. Qenerator ID Number C, (C-0011\0 \ 5-7' 2 Page 1 of 3. Emergency Response Phone Sl)o -0-9- 1136 4. Manifest Tracking Number 0 1 9 70 39 0 2 JJK Generator's Name and Mailing Address 1 C.. (..._ r: c f.......1901, Generator's Site Address (if different than mailing address) 1 0 Voe, (•\/k- b v tc 1-anC) ii.c.c1( f< ‘S-1-1(} • fV.S-if4 QS). 1-Q,c,f<ND it) ( A,qs'-'6- 131:37-1‘ Generators Phone: (1 IA crol Transporter 1 Company Name U.S. EPA ID Number k)C\WZN N \A torvrin\tit- ekkkts I iNk) K310210 419 7 Tran orter 2 Go pany TA , Name I -. 0 v e,<, thin lA ,1 c U.S. EPA ID Number 8 Designated t_icA5 Faciliry vNIele and Site Addr !_c-* ess U.S. I:PA ID Number tr,,, ovtrNc) 0 seeA clt. 9 413 I Q 07.g 1(090 I 1 ga. Pb. U.S. DOT Description (including Proper Stripping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HMand Packing Group (if any)) No. Type Quantity WI /Vol. N Wv — out N I-1A --i040,,5 t406\-(, D i .s()C, r Z (fp)e), c\c."5) 9n ) -to s> 14. Special Handling Instructions and Additional Information A ))-13,- Ov 113LI . ) x 95-0? vo s-93„ (;) 0 6 it CeCt t. q 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, aid are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and tam 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 lam a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year - O( V26-,(4 ____----- oil II 1 Li _, I— g 16. International Shipments LII Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: Ce 17 Transporter Acknowledgment of Receipt of Materials TRANS PORTE Transporter 1 Printed/Typed me Signature Month Day Year 1 0 LI 11 I n Transp r Printed/Typed Name c_ IA C L.024--eA-7 Signature Month Day Year _c--,, 1 . 1 0.1_I Ik12.2_- , 4----- DESIGNATED FACILITY 18. Discrepancy Discrepancy Indication Space LI Quantity LI Type LI Residue Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone! Signature of Alternate Facility (or Generator) Month Day Year 19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal and recycling systems) 1 H \ 4 I 2. 3. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printed/Typed Name Signatur 6 _ Month Day Year EPA Form 00-22 (Rev. 12-17) Previous iitions are obsolete. DESIGNATED FACILITY TO EPA s e-MA I