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bit V <br /> r7eTranspoder2C <br /> rlype. <br /> 1 . Generator ID Number Form proved, OMB No. 2050-0039 <br /> M HAZARDOUS 2, Page 1 of g; Emergency Responso Phone 4. Manifest racking Numbor <br /> 7E NUINIFEST i r n ' r : 'l t� <br /> lorsNameendMaiMpAddress "i nr � .` t EJ � �116 We IGeneratorsSiteAddress pf dlgerent Ihen nti311ing address) <br /> rs Phone:orter 1 Company Name <br /> U.S. EPA ID Numberrter2 Company Neme ,S. EPA ID Number <br /> ted Facility Name and SiteAddress <br /> < <, � .: : . '16 r;: r i : : ; . U.S, EPARol Number <br /> too <br /> Facility's Phone: _` ' <br /> pa, 9b. U.S. DOT Desalption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br /> HM and Packing Group (If any)) l 11 . Total 12, Unit 19. Waste Coles <br /> a 1 . . . . <br /> 1 No. Type Quantity Wt.Nol. <br /> 3. <br /> � 1 <br /> 4. <br /> 1 <br /> 14. Spec el Handl ng Instructions andAddifions Informs on <br /> L <br /> 15, GENERATOR'810FFEROR'S CERTIFICATIONk I hereby declare that the contents of this consignment are ftiland accurately described above by the proper shipping name, and are dassirred, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to appllcabie I tomallonatand national governments[ regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknovrletlgment ofConseni. <br /> I cerdty that the waste minimization statement identified In 40 CFR 262.27(a) (if 1 am a large quantity generator) or (4) (IQ am a small quanitiy generator) Is We. <br /> Generatoral0(ferore Printed/Typed Name Signature r: - <br /> tttttottMonlh Day Year <br /> 16, n ernational Shipments �. y ,f ( " It <br /> El Import to UIS. ❑ Export from U.S. ' Port of entry/exit: <br /> Transporter signature (for exports only): Date issuing U.S.: <br /> I= 17. TraneporterAcknowledgmentofReceipt ofMaterials <br /> Ix <br /> Transporter 1 Printed/Typed Name Sipnalure <br /> a Month Day Year <br /> I It <br /> Trensporter2 Prints yped Name Signature k <br /> Month Day Year <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication SpaceElQuantity ❑ <br /> Type Residue ❑ Partial Rejection ❑ Full Rejection Pan <br /> 18b. Alternate Facility (or Generator) asl Reference Number. <br /> j U.S. EPA ID Number <br /> W <br /> FaclBtyone: <br /> 'sPh <br /> I <br /> 1ec, Signature o Alternate Fac by (or Generator) <br /> Month Day Year <br /> 18, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposuj <br /> es, end rehyding systems) <br /> O 1. 2. 3. 4. <br /> ")' a <br /> 20. Designated Facility Ovmeror Operator: CerUAcalion of receipt of hazardous materiels covered by the manifest excgptas noted in Item I <br /> P nled/fype ame Signatureti I Month Day ear <br /> EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete. I g3r6tTED FACILITY TO GENERATOR <br /> 4 <br />