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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 WASTE MANIFEST 1 019921873 F L E 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing addressi -�ni n r Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 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 HIMyj)M and Packing Group(if an No. Type Quantity WINoI. 1. t .;JL 0 C W Z 2. W 3 4, 14.Special Handling Instructions and Additional Information 1) LAVS22956 CAE- 02 ,<;3z r 2) EWS4416 CAC- 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmem are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabe fallplacarded,and are In all respects in proper condition for transport according to applicable intemafionaland national govemmental regulations.ff 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)(AI am a small quantity generator)is We. GenereWrsl08erors Printed/Typed Name Signature Month Day Year cs3 a(C, F 6.International Shipments ❑Import W U.S. ❑amn from U.S. Pod of entrylex8: = Transporter signature(for exports only): Dateksving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials aTransport/ n typed Name �� Signature �� Oth Day r z Transports 2P' f/N'Dame Signature Monti Da Year } 18.Discrepancy laa.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z H19.Hazy Waste epqrt Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility r or Operator:Certification of receipt of hazardous materials covered by the manifest cat LA s d in Item 18a PdntedRyped Name i Si ate net asr EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILI MANIFESTSYSTEM