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U.S EPA ID Number <br />• d <br />US. EPA ID Number <br />U.S. EPA ID Number <br />12. Unit <br />WdA/ol. <br />Yle) I kl:DS <br />16. International Shipments ID Import to U.S. <br />Transporter signature (for exports only)' <br />17 Transporter Acknov4edgment of Receipt of Materials <br />Tranrler 1 PrintediTyped fdante <br />0300 <br />Transporter 2 Printed/Typed Name <br />18. Discrepancy <br />180. Discrepancy Indication Space fl Ouantity <br />18b. Alternate Facility (or Generator) <br />Facility's Phone: <br />18c Signature of Alternate Facility (or Generator) <br />19 Hazardous Waste Report Management Method Codes (i.e <br />fl Export from U.S. Port of entry/exit: <br />Date leaving U.S.: <br />Month Day <br />it 12. <br />Month <br />t <br />Month Day Year <br /> <br />El Residue <br /> <br />Type <br /> <br />ri Partial Rejection 1: Full Rejection <br /> <br />Manifest Reference Number: <br /> <br />4 • <br /> <br />U.S. EPA ID Number <br /> <br />Signature <br />Signature <br />t, Please print or type. <br />5 Generator's Nerner 'Wading AddressE"g4rAciee SC6) 6.1)1-6 11 <br />UNIFORM HAZARDOUS I.Generator ID Numbe <br />2 Page 1 of 3. Emergency Response Phone WASTE MANIFEST CAC,ChS> 3 3.42, 5-g. 4 Manifest Tracking Number <br />/Pig W. A40r-ci, Levee. <br /> Generator's Site Address Of different than mailing address) <br />3C, 0 21 3 9 5 3 6 0 J <br />cA <br />Generator's <br />8 61sparter,1 Company Name ; <br />7 Transporter y Name <br />Name and Site Address <br />Cry5+0,1 lean L.L6, I (fie E rDA,41.0t.qt, /-calt-Z3j..b.-51a:c,1 4 ,C4 gni," <br />1178 -5. e> Facility's Phcifte. <br />GA‘ovoz <br />13. Waste Cod, <br />35-2 <br />233 <br /> <br />cia <br /> <br />LU <br />roved. OMI) 1. <br />/0y1-- gazaintoo5 Wov5+C-1 50i;C3 <br />A6r4ce,o- 0,..6 s 14;44/1 Pie-Set) <br />Jot Rc*A kazorcbos wrAiA-c, <br />\Jcvl-ct u 7441 Wc...se,%) <br />Sb :1 S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. <br />' 'asking Group (if any)) <br /> <br />10 Containers <br /> <br />(p <br />No <br />"Piti <br />Type <br />15 <br />270 <br />11 Total <br />Ouantity <br />4, <br />4 Special Handling Instructions and Additional Information <br />)) <br />co <br />odes for hazardous waste treatment, disp sal, and recycling systems) <br />3. <br />20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as satedItem 18a <br />Pnnted/Typed Name tn <br />Signature <br />-54* H 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, package) <br />Exporter, I certify that the contents of this consignment conform to the t erms of the attached EPA Acknowledgment of Consent. <br />marked and labeled/placarded. and are in all respects in <br />proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and tam the Primary I certify that the waste minimization statement identified in <br /> 40 CFR 262.27(a) (if tam a large quantity generator) or (b) (if I am a small quantity generator) is true. Generators/Offerorts Printed/Typed Name <br />Signature <br />Month Day Year <br />Month Day Year <br />DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.