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Form Approved.OMB No.2050-0039 I <br /> Please pnnt or type. 4.Manifest 7rackin Number K <br /> 1.Generator ID Number =Generator's <br /> .Emergency Response Phone 019 I 0 4 2 6 8 J J, <br /> UNIFORM HAZARDOUS p 6� b Z il I?b <br /> WASTE MANIFEST CAC 6l y 0 1D 1 J <br /> Site Address(if different than mailing address) <br /> 5.Gnerators N M <br /> an ailing Address <br /> I,�IMq �� n $So N 1'f1ac�,rlhti� WY <br /> >,S-ZLI CAYk- �f G� g, 5dhnsc�► 'I,•o�c (-R �IS3�lo <br /> Gene tots fid' CA 6)S3S1 'i bH6- m*1-2a <br /> U.S.EPA ID Number L46.Transporter 1 Company Name s I (5 S 3$b 6-49 <br /> (2E-Y)VAYOVI M017"eyl U.S.EPA ID Number <br /> 7.Transporter 2 Company Name I <br /> U.S.EPA ID Number <br /> 8.Desapo F Iihr Name V ite or b <br /> I g S O ''6 [I-I'll" � YY•11 <br /> rracws Pho e <br /> LoN <br /> f3�a,. �g ��st3 csea�H��-s�NS cin Qa$ o� q <br /> ID Number, 10.Containers 11.Total 12.Unit all 13.Waste('odes <br /> ga- 9b.U.S.D01-Description(including Proper Shipping Name,Hazard Class, Quantity Wl.Nol. <br /> HM and Pacldng Group(d any)) No. TYPO <br /> NA t"I3 �t�s-te {S�1 'f.�c1,3)?t 0M B60 <br /> P 3 <br /> °t <br /> o OdOI <br /> Q <br /> LU <br /> LU <br /> z <br /> LU <br /> CD <br /> 3. <br /> 4. <br /> 14.Speaal Handling Instructions and Additional I f, atQn� <br /> ��i1�'II,tx��g'g <br /> f# qS Boll <br /> 15. GENERATOR'S/OFFEROR'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, <br /> • marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a la ge quantity generator)or(b)(if I am a small quantity generator)is true. Month Day Year ) <br /> t 9 <br /> Name Sig <br /> C-enerator'sfOfferor's Printed/Type� k�� a 3 <br /> s, AmL m00VLt <br /> j f .I emational Shipments Import to U.S. Export from from U.S. Port of ngU.S.:entry/exit <br /> Date leaving U. <br /> ? Transporter signature(for exports only): <br /> 17.Transp rterArknowledgment of Receipt of Materials Month Day YLLIear <br /> T sporter 1 Printedffyped Name e <br /> �10 ZS � <br /> a <br /> a If �ilL I Month Day Year <br /> Z Transporter 2 Printedrryped Name Signature <br /> Q I I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceQuantity ElType ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> F}- 18b.Alternate Facility(or Generator) <br /> J <br /> U I <br /> it Facility's Phone: I Month Day Year <br /> w 18c.Signature of Altemate Facility(or Generator) <br /> Q <br /> Z <br /> NI, <br /> Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 2 ;i. 4. <br /> O 1. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Month Day Ye�r <br /> Printed/Typed Name Signature <br /> EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's E:-MANIFEST SYSTEM <br />