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fs 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 Trackl+n Number WASTE MANIFEST f ,��liX},� � j t 019 L i 4 0 i 8 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) PRO ON Wilt FILLEFT SFF7 1('`. S X4C 1'C-CKTON,Cry rte,' 15 Generators 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 31 1'PK,' 1 KVJ, Facility's Phone:8WA99-Z1-45 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 Wt.N01. 1. Fiicm Rcrtk f,,AzAtr1 iu-'..ti (STEF-L Z 2. cy/ �J 3. � /v 14.Special Handling Instructions and Additional Inform 98.I`•+R0f'tLF'* eR..f,•"r#.. , E.R."CON�MCTOk RAW03 E(VWC&JWNTA.a.. / S c� r b'UC/�e RAMI ERS SHIMLD t*TRAN4EID ABO L1.9E APPROVtED PPr- 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,1 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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/Offeroes Printedffyped Name Signature L� , -• Month Day Year 16.In 6mational Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: a! 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a Z Transporter 2 Printed/Typed Name Signature Month Day Year F- 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 Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY