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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I'. Generator ID Number 2.Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number (� WASTE MANIFEST L :'.I_QU0040U3U OO ' : } 9 DAT 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) A.TiP1Y�al , :, Generator's Phone: 6.Transporter 1 Company Name U.S. EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number r t;aril ('..l=t�! F3Y!?R-rNIOYs�I . 8.Designated Facility Name and Site Address U.S.EPA ID Number li ' ti i);, t'' n�1},iAfi(lUif)(tfh5'N^' , Facilitys Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class, ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WtNol. 1 q�.:,..}:r,'}.a�y. 1"i`!.-irftl}tS" 1M1Irt3tt. 1.41 I't.t {.SiSrC kid, FAVI'8iltA) I z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Information 01: (U!'U13161U-2t M6,INI I H1 I E YJ6a l LIR(ES I VIALS I f't f t •�" } r}F"Wh -..i tn'f-1VWrAlor;nrrfi r" w7Mli p]atrr v*#,/on irb1.0 trPrnlf/M!T 1.1 441 n+ +401140!n1t4'34P05r.1rA r 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 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)(if I am a small quantity generator)is true- Generators/Offerors Printed/Typed Name Signature Month Day Year J 16. International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.TransporterAclmowledgment of Receipt of Materials Transporter 1 Printed7ryped Name Signature Month Day Year a Z Transporter 2 Printed7Typed Name Signature Month Day Year H 18.Discrepancy 18a.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 Facilitys Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 Printedfryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOW< S INITIAL COPY