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Please orint or tyoe. Form Approved. OMB No. 2050-0039 4\ GENERATOR > 1 UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator I <br />C <br />Number <br />Coo3/ 7 L(6,Z 4-( <br />2. Page 1 of 3. Emer ency Response Phone <br />&-g 6 ' Wo <br />4. Manifest Tracking Number <br />0 2 2 2 2 8 3 7 8 JJK <br />5 Genertoes Name and Mailii g Address Generator's Site Address (if different than mailing address) <br />PeAikt /2_ aceAdiAj Pfr <br />Up 7s--- Mtor-004-0/Aot, . . , 1/ <br />3 7 'is fq -/ IN -Iz-1 -zz_/2-c? .`1 I-) <br />Generator's Phone: n Li 11 ?Li 7 - 96. 71 19(o011 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />A kez I A) 5 e r v if e5 I CA 09(0737063 <br />7 Transporter 2 Company Name U.S. EPA ID Number <br />ht'veYcZki I-A- 6 'MI,' C . C. . L C.C, I <br />8 Designated Facility Nail and Site Address U.S. EPA ID Number <br />Cr0;b V 4- Over-1-0h, <br />i(001 (,') i . 1 IL11. 5 4-re--€4 Le) ee,cdtc-A-, 9p3 C A D olit(17 90 9 <br />Facility's Phone:57Np__ <br />ga. 9b. U.S. DOT Description (including Proper Shippi6g Name, Hazard Cldssinumber, 10 Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity WI.Nol. <br />1 <br />V OW /g4 kki L 62 rJ- MA /e,Yo/4 zJ <br />( Ofr/50( 5:0 i'L) <br />00/ PAn i - 5-6 <br />/ <br /> <br /> <br /> <br />14. Special Handling IiispcVnd Additional triton:114°n baleekr trailer , p fc, <br />tog& <br />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, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations. If export shipment and I an: the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Admowledginent of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if lam a large quantity generator) or (b) (ill am a small quantity generator) is true. <br />Generater's/Offeroes Printed/Typed Name Signature Month Day Year <br />- 0 A Otttaif of bei4etae re- )iipp- aticts1- /A.?, -/.dze.<- 1 5 1 1-/ 1 21- <br />_, <br />I— <br />..?.... <br />16. International Shipments Ll Export from U.S. Port of entry/exit: Import IOU.S. <br />Transporter signature (for exports only): Date leaving U.S.: <br />itt <br />I— <br />(3--- a. <br />= <br />17 Transporter Acknowledgment of Receipt of Materials <br />LU Transporter 1 Printed/Typed Name, Signature Month Day Year <br />j deg, /J OC,Lat' 4(44, 0/Z1 I 5-1 11 I 21—' <br />--) <br />Transporter rinted/Typed Name Signature Month Day Year <br />cit--- IR 6 (r•...i/L__RA ei -A_ S--"C^- I OC—I ( 3 I 1--t- I 4--- DESIGNATED FACILITY -4 17 M. Discrepancy <br />18a Discrepancy Indication Space n Quantity 0 Type LII Residue LII Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />13c. Signature of Alternate Facility (or Generator) Monti Day Year <br />19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 2. 3 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except Med in Item 18a <br />Printed/Tyra n A n r ._ , Signature <br />t-34V-Ue. 0 I <br />) <br />.,...........•.............._ A .r.e. 1,•• -re. r.rt A 1— _ <br /> <br />Monjh Day Ye a- <br />._) I a) 12 <br /> <br />. A k i i r r csVCTI:nt <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. -