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Please print or type. Form Approved,OMB No.'12050.0039 <br /> UNIFORM HAZARDOUS Generator ID Number 2,Page 1 of: 3,Emergehq Response Phone4.Manifest Tracking Number <br /> WASTE MANIFEST —800-11`14--.0—.1780 <br /> IM7440716- 8 SKS <br /> 5.Generator's Name and Mailing Address Generator's SlIeAddress(if different than mailing address) <br /> P',-i)i e r Ji I--,, I•r i� 1 1!��j1(j i-I fj <br /> 3 JM 1"! <br /> 37-5,5 <br /> S Tri r: <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> G[J""AIN <br /> 8m Mignaleffacility Name and Site Address U.S.EPA ID Number <br /> ILI <br /> F1�4i_L <br /> Facility's Phone: 410 U. <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contal ers <br /> I 1f.Total 12.Unit <br /> HM and Pacyng Group(if any)) 13.Waste Codes <br /> No. Type I Quantity,, WUVol. <br /> -.3 <br /> D N V."1' "K-3, <br /> 0 <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1 0 V 1� W1 <br /> —G-o-fit r <br /> MV <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national Irameptal regulations.If export shipment and I am the Primary <br /> Exporilayl <br /> -6dify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent./ <br /> I certify Ifia I <br /> t,the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am f�smqll quantity goi)brator)Is true. <br /> [Generatoe', ff&c?s PrintedfType Name Signature <br /> Month Day Year <br /> _j 16,Internatignal Shipments <br /> ❑Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature,(for OXPOS only): Date leaving U.S.: <br /> 17.TranspDrierAcknDwIedgmerill of Receipt of Materials <br /> Trarisfibrter 1 Printedfryped.Name Signature Month Day Year <br /> 0 <br /> CL <br /> Transporter 2 Printed[Typed Name Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> 1:1 Quantity HTypa ❑Residue E]Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> :3 <br /> 1<1 Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Genero[OF) month Day Year <br /> Z <br /> f9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3, 4. <br /> 20.Designated Facility Ownof or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> PrinladfTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />