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Please print or type. Form A croved. OMB No. 2050-0039 I GENERATOR t. UNIFORM HAZARDOUS WASTE MANIFEST 1, Generator ID Number _ , le e ,. 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJK 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) c Generators Phone: .‘ :i, . :., I Transporter 1 Company Name U.S. EPA ID Number - 1 '' I Transporter 2 Company Name U.S. EPA ID Number I '8. Designated Facility Name and Site Address U.S. EPA ID Number `v...f.'-, 1 . rt..: .30qt . ,- • , ttf$4111 Facility's Phone: . .', a 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit NM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes i.q: pv1/4 r,..6- 4,- .,...., . i,., A 1 14. Special Handling Instructions and Additional Information 1) impl1114114:444/14)6., POS lab/ 22.160211 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, ard are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemtonaland national govemrnental regulations. If export shipment and I am the Primary Exporter:I-certify that the ConteMtt -Of thirciarisr9rVninfainkirm tattle 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 quality generator) or (b) (ill arm a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year 4:Ji 1 I 4. 4., • . ' I I I _j I- _?. 16. International Shipments ri Import to U.S. Export from U.S. Port of entrylexit: Transporter signature (for exports only): Date leaving U.S.: 'TRANSPORTER] 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year I I I I Transporter 2 Printed/Typed Name Signature Month Day Year I 1 1 I I 4--- DESIGNATED FACILITY -0- 1 18. Discrepancy Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal. and recycling systems) 1. 1 2. 3. 4. . 20. Designated Faddy Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncied in Item 18a Printed/Typed Name Signature Mirth, Day Year .. I_ . .......,„ ..... EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. - - DESIGNATED FACILITY TO GENERATOR