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Please print or type. E Form Approved.0Mt3 No.2050-0039 UNIFORM HAZARDOUS 1.Ganerator ID Number 2.Page 1 of 3.EEme1��ee� R�spp a P�haptq 4.ManifestTrackingNumber (� (� WASTE MANIFEST ?:; !_.f t� j 1 i�#:3.�•"E ? S 'tr , o r t, r 9 5 r1..+ V , ,7 5.Generators Name and Mailing Address Generators Site Address(f different than mailing address) tint Generator's`Pl cne: B.TranspRrler.]Company,Name U.S.EPA ID Number I X H 0 0 01.0 17, 7-'transporter 2 Company Name U.S.EPA ID Number t (tr € FT� _Ia+,f i? t'.fikcIt't #ai_ tl :It.K 1474f $i? c -&� S.Designated Facility Name and Site Address Cl - M I•iARI ORS C;AN Jcl�A- U.S.EPA ID Number Or.! AOPYI-SSA ROAD Facility's Phone: ga 96.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(f any)) No. Type Quantity Wt.Nol. 1 a =1 WASTE SCS:_;li; o t 3 , � 'r,t:t i,;t_sta.r;"NAT!= WTTH €,11I-) /A a w 2. Pdg..ta; r` it 4 4 ti 31 f 2.?f..t , �*43TtC _11 1�? r > C7 3, 4. 14.Special}candling Instructions and Additional Information T r. ,e -S,. , 0 J Ell .,t;H rMiF_ 5�5 i.`f# I ...1}t;!�-.^''f St.,�.�:`i,r- t �'�'�• t:s 4 r„;�: s 4 w �i�.. � s-'�k�r; ^�t.:t r-��i;��+� by tea, ..s�.f �� .::f�� . ��' , �t��:��-t�;�>� �+.t t1Dr t " a]. �r t i-C 112 aril s '# ! .Y1 � i i i r: ii` r2 t. - tr^, f` 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 labeledlplecarded,and are In all respects.+n proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Pnmary Exporter,I 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(x)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. GeneratorslOfferofa PrintedfTyped Name Signature- Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S Port of entrylexft: ? Transporter signature(for exports only): Date leaving U.S.: LU 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signator n e Month Day Year a jam:" zTransporter 2 Printed/Typed Name Signat e M nth Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ ouanti ElT e ty Type ❑Residue ❑Partial Rejoclien ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J V res 'Facility's Phone: ua[t 18c.Signature of Alternate Facility(or Generator) Month Day Year fr Z 19.Hazardous Waste Report Management Method Codes((e„codes for hazardous waste treatment,disposal,and recycling systems) 3. 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as tided in Item 16a PrintedlTyped Name Signature Month Day Year EPA Form 87000-22(Rev,12-17) Previous editions are obsoiete. GENERATOR'S INITIAL COPY 7-;