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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number �e 1 of 3.Emergency Response Phone 4.Man est Trg WASTE MANIFEST 0 1 FLE- 5.Generator's Name and Mailing Address t Generator's Site Address(if different Than mailing address) v `)(4!A V 0,C I ti f r,tit 1 'j C;�:F r-'-K , 64A '36OR Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 6 j,%i r(,! AJ r� L il-, _:J 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number AJ V 1h - . I m 4 0 � 14 10ir,- �-1 I T4 j f tJ\1 qci 4 00 -7 Facility's Phone: "7"-7.-'r-_J -'5-2-7 G"D I 9, 9b.U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity WI.Nol. 13.Waste Codes 0t 'K I L C :7 P 03 k f- n I' <r)I�1..iPiPJI X 3. 4. 14.Special Handling Instructions and Additional Information J 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 EPAAcknoMedgment 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)(if I am a small quantity generator)is true. Generator's/Offerors Printed/Typed Name Signature Month Day Year 16.International Shipments 11 Import to U.S, El 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 LL1 Transporter 1 PrintedfTypqJ Name Signature Month Day Year 0 Z Transporter 2 Printed/Typed Name Signature P/I Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity 0 Type 0 Residue Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number -J U LL Facility's Phone: C3 LLj 18c.Signature of Alternate Facility(or Generator) Month Day Year tR Z I 9 I I 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) U) 0 LLI 1 2. 3. 4. 1 1 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed7fy—ped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY