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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number p „ , eF .ii f WASTE MANIFEST CS J, : s _. .. ( e 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) I 1 11 Zr Generator's Phone: ' 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number , k' o : . 8. Designated Facility Name and Site Address U.S. EPA ID Number 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 Quantity Wt.Noi. ) , , t . O 21 ua c� 3. 4, 14, Special Handling Instructions and Additional Information It 1 s i 15. GENERATOR'SIOFFEROR'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, 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 I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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) (ifi am a small quantity generator) is true. Generatoesl0fferoes Printed/Typed Name Signature Month Day _ _ Year r ' r f i' j 16. international Shipments F, ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials 1� Transporteril PrintedlTyped Name Signature 's f Month Day Year r, CL O , Transporter 2 Printed/Typed'Name SignatureMonth Day Year- Iva F,Y 7 T18. Discrepancy 18a. Discrepancy Irv' cation Space [I Quantity ❑ Type ❑ Residue yp ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) ?jj (l yS j P If3 Nu[gbW a LLM Facility's Phone: for ars 1 wl i LU 18c. Signature ofAlternate Facility (or Generator) Tfa ' w � g, srt3kgl4 is y_, £lippillMonth Day Year Q z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1 . 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped Name Signature Month Day Year t EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.