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print <br /> r e Form Approved.OMB No.265"039 <br /> ease pr nt or HAZARDOUS� 1,,r�Gftene�ra9tor ID Number ��+'�/ t 2.Pagpe 1 of 3.Emergency Response Phone 4,ManHest Tracking Number <br /> UNIFORM E MAN ESTUS (2 4 -r o o t.,l & i S( .f 7 <br /> ter's Name and Mailing. ddress .. y Gr atofS Site Atl ss(if iff rent th n tlln ddres4).«.,�: r' f"' .gg maQPL a aP�4 } 7p19 <br /> s Phone: .��4Jq v .') — 1' 3, � r_ti t � ° •"S` i,3 � p "1.5 �` C'm <br /> er 1 Company Name f '� U.S.EPPA I,D Num�'bgei"," >,� C,,.!"1 t' @�' 'u y 1 , "i-'? ram' .•ti;;-.k W:w tr r �+' , �. ,...�'; , !�k ✓•, 4Jrter 2 Company Name U.S.EPA ID Number <br /> ted acility Name and Site Address .- U.S.EPA ID Number <br /> JNA <br /> Facility's Phone: 't ° t i �; � 1 � 4 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity : WtiVol, <br /> sR _ ¢ <br /> o <br /> a <br /> W <br /> w 2. I <br /> CD <br /> 3. <br /> , <br /> 14�S,p=aal Handling Insigtcti and ditional I ,fomia6on <br /> t ° _7 <br /> Nr -7 <br /> 15. CERERATOR'StOFFEROWS CEIMFICA'nON: 1 hereby declare that the contents of this consignment are fully,and accurately described above by the proper shipping name,and are classiffed,packaged, - <br /> maixed and labeledlplacarded,and are in all respects in proper condition for transporf according to applicable international and'national governmental regulations.If export shipment and.I am the Primary <br /> Exporthr.I' `thatthe contents of this consignment conform to the terms of the attached EPAAcknowled'gmeht of Consent <br /> i-cer5iyb. atthe waste minimization statement ideritified:in 40 CFR 262.27(a)(if lama large quantity generator)or(b)(if l'am a small quantity generator)it true. _ <br /> Geneam'sl06erofs Pnn Name Si natureJay <br /> 9« P_ nrC4 Year <br /> � 2 <br /> 1 16.Intemaliortal Shipments .. -- <br /> -F ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z Transporter-signature fore orts on <br /> <: g <br /> ( exports ty). - Date leavin U.S.: <br /> _- . <br /> M� 17.Transport:rA6;novdadgmentofReceiptofMaterials <br /> Trsporpr1 P6nted,7yped Ndine Signaur Mon Y <br /> ) / <br /> Transperter2Pnrned5ypedNa "e Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Disaepaney Indication Space <br /> ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> U .. - <br /> LL Facility's Phone; <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Yea! <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1, 2, 3, 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name <br /> Signature Month Day Yea: <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL CO' <br />