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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST I:.)H�yrt:'.'�r= r <br />r0187900 <br />2 JJK <br />S. Generator's Name and Medina Address Ganamtuln Site Addroee (a different men mailing addem) <br />1,-,r .i. .kttefdr,F¢';,:.': FD <br />Generators Phon553d-4T <br />6. Transporter 1 Company Name U.S. EPA IO Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />9. Designated Facility Name and Site Address U.S. EPA ID Number <br />.r.•; F':1 i•4.%-44-f-0lf'. f• <br />FaciliNs Phone:' ' .1 <br />9a. <br />9b. U.S. DOT ! esviption (including Proper Slipping Name. Hazel Claes, ID Nimber, <br />10.00,14811 <br />as11. <br />Total <br />12. Unit <br />HM <br />and Packing Grup (,'any)) <br />Quantity <br />Y1M,No. <br />13. Waste Codes <br />No. <br />Type <br />1. Fpr'rr .. a Jr,1 Of <br />.. e <br />. <br />a <br />Z <br />2. <br />(\/��� <br />EIVED <br />RRECEIVED <br />a <br />3. MAY 2 2018 <br />4. ENVIRERWEll <br />HEALTH DEPARTMENT <br />14. Special Handling Instructions and Additional Information <br />4DJ11`F(iF'ILtiM i-iP.r�/f:-I h t - !'. <br />EP. 1: r:dFlTPst{, 0F. JR01.112). f'IH"N?frigf:lEtdT�'t <br />H.1DR"i'r F, > X14001 B P)F 'IFT,-y FO daO 11'bF--.PV'^ir fiD I'm'1 �. <br />1 <br />15. OENERATOR'MFFEROR'S CERTIFICATION: I hereby declare that the contents of live consignment are fuly and accurately described above by the proper shipping name, antl are dassified, packaged <br />marked and lebeledripacerded, and are in all reaped; in proper condition fa transport according to applicable mtemalional and national governmental regulators. If expel shipment and I am the Primary <br />Exporter, l unity that are contents of this consignment conform to the terms of the attached EPAAckro'Medgment of Consent. <br />I certil that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity, generator) a (b) (ifI am a small quantity generator) Is true. <br />Generalprs'Offera's PrintedlTyped Nam Signature Month Day Year <br />J <br />F <br />16. International Shipments <br />E] Import to U.SExport from U.S. Port Of entrylexlt: <br />Transporter signature for exports arty): Date leaving U.S.: <br />w <br />17. Transporter Ackncedetlgme l of Reoelpt of Material <br />`ransporter 1 PdntedrfyUed Name Signal Month Day Year <br />O <br />y <br />i <br />zQ <br />Transporter 2 PnnteN ypetl Aanne " Sin re Month Day Ye9r <br />K <br />f <br />.} <br />18. Discrepancy <br />18s. Discrepancy Indication Space ❑ Denial ❑ Type ❑ Residue ❑Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Aaemete Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />Facility's Prone: <br />w <br />file Signature of Alternate Facility far Generator) <br />Month Day Year <br />Q <br />Z <br />y19. <br />Hazardous Wade Report Management Method Codes (i.e., codes for hazardous make treatment disposal, and racial systems) <br />G <br />1. <br />2. 3. <br />4. <br />20. Designated Fell Deaver or Operator. CemBcamn of ram ptof hazardous matherals Fawned "a manifest except as noted In Item 18a <br />VIII' <br />Prntedrfypad Nam Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />