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06/21/2018 11 :07 12099412226 Country Marketplace :3941 P. 003/004 <br /> Please*1 or type.(Form designed for use on eke{12-pitch)typewri ). Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator D Number 2.page I of3.Emergerray Response Phone 4.MarOW Tracking Number <br /> WASTE MANIFEST EX-V1,9- A7 018790134 JJK <br /> Geneeralo(s Nam and Mailing Address Generator's Site Address(if fferW than=FN address) <br /> Generators Phonff;,e.,-. ug <br /> 5.Transporter Compar�p ,; U.S.EPA 10 Number <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> $.Design rbd Facility Name and$Re Address U,S.EPA ID Number <br /> FAcilVo <br /> 9b.U.S.DOT Description(iicluding Proper Shipping Name,Hazard Class,ID Number. 10.Conrainer3 11,Total 12 unit 13.Waste Codes <br /> tjM and PsoVrg Group(ifany)) No. Type t7uentitY V*-Afol- <br /> ir .. <br /> X 2. j�.q 315. STE F SCAA), W"G'.4.i,P'T' <br /> LU <br /> 3. <br /> 4, <br /> 14,9pe3al Handling Wtvocns and Ammonal In%miation <br /> o P'K. <br /> A10 Z <br /> 15. WNERAMw51oFF1KW3CEMFICAT*N:I hereby declare that the to(AMIS of this onj9pment are fully and aoruratelydeautped above by the proper shipping name,and are cbmified,pacloged. <br /> mariced and kibewMawn:14 and are in all respects in proper condition W nmpw aocor"to applicable international and mti*rW governmental regulations.If export shipment and I am the Primary <br /> Exporter,I c**M the oonrtwn of this consignment omfoin to the terms of the attached EPA A*wdedgment of Cormnt. <br /> I certify that the waste minlabEft sbrtwnent identified In 40 OFR 262.27(a)(if I am a large quantity generator)of(b)(If I am a Small quap.*generator)is truk <br /> Gwomtoes/Offaroes PyintedMwed Name Si"w Month Day Yea <br /> -j 16.Intemabonal Shipment <br /> I-- Ej kw to U.S. M Export ton,U.S. Port of entryiwk <br /> K Transporter signature(for eXPOM only): D&leaving U.S.: <br /> IX 17.Trenspoftr A*cwleedgment of RaWpt of Mawfi& <br /> lure Month Day Year <br /> yr Transporter I NrftdRYPed74rh* <br /> Z Transporter 2 PfhedfTyped Name MOM Day Year <br /> 15,L)wjepancy <br /> 18a.DismpahtY Indication Space 1:1 Quatits El TYPL ❑Residue El Partial Rei MI ❑Full Rejection <br /> Marifev Reference Number. <br /> 76b,Afterriate Fack(01 Ge~ U.S.EPA 9)Number <br /> 73 <br /> two. Faciflys Phone: <br /> UOLI likSignature ol'Allar nateFaaft�(orGcnorator) Lwth V4 Year <br /> !a I I <br /> Z <br /> 10.Hazardous WWe Report Management Method Codcs(i.e.,c4ft for hmrdow waste treatment,disposal,W4 reqdng systems) <br /> wry T. �] rj4:. T _ , RONMENTAL <br /> ity owwr or Operator except as ruled in Item 18a Wr:Aj T r,,r7PPkRT�N',V <br /> 20.Designated Fad cerffmton of receipt of hazardous Major!&Covered by ft owde% <br /> ftledffyped Raw Signature Month Day Year i <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />