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Tim Please print or type. - Form Approved.OMB No.2050-00 9 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page Emergerncy Response Phone 4.Manifest Tracking Number r WASTE MANIFEST QA-4 0C) 3�4 Z b / V J G v 1040 020804834 FLE� 5.Generator's Name and Mailing Add�rLess �� 'co Generator's Site Address(if different than mailing address) 2 c -R �a�r� $ cedCo a l l QtCI,hNa�� cry or�`�s�� t �rs �a�� / RI GA gf3a Generator's Phone: r-(p 6 F2-4'— 6 6 6.Transporter 1 Company Name U.S.EPA ID Number AA4 M k 1L Uk,Amer L-v A K oock SS ,-1 3 7.Tran any er 2 Co Na mg U.S.EPA ID Number 14401,1, i1 C �; ��t Q q01.�i 8.Designated Facility Nske and Site Address "S - U.S.EPA ID Number lL3c� V i}Jr-+ sk U^ s�►• C ta a o W C r� 2v Facility's Phone: 3� t4(.( �p vl r` Gr q 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HIM and Packing Group(if any)) No. Type Quantity Wt.Nol. �, 75c° UJIw 2.nun N✓nn -tltszc\",o �e I, ?, p zz3 3 a. ' 14.Special Handling Instructions and A tional Information ?w k5o M —7 q� 1'3d113 qv ) a-� �3 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 EPAAcknowledgmentof 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. Gener tor's/Offeror's Printed/Typed Name Sign atur n Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? ransporter signature(for expolts ): 4; Date leaving U.S.: w 17.Transporter Acknowl ftf Reeeipt.of Materials Transporter 1 Printed/T ped Nafhe '-� Signature Month Day Year a ` _ V I5 1 Z Transport# 2 Print e T ed Namg Signature Month D Ye Lrt ancy - 1Ba.Discrepancy Indication Space 0 Quantity C Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: Fr— 18b.Alternate Facility(or Generator) U.S.EPA ID Number J v LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year . Q Z U519.Hazardous VVarta Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. - 2. 3. 4. ' 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. " . -; i ( y T P "sA*I j T Y