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{ <br /> Please print or type. Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1, Generator lD Number 2. Page i of 3• Emergency Response Phone 4, Manifest Tracking Number <br /> WASTE MANIFEST A t _ t <br /> 1 1p r Wit . ?'_ 'Ia_ ' r. ( Ytl <br /> 5. Generator's Name and Marling Address Generator's Site Address (if different than mailing address) <br /> Generator's Phone a>> .-_ -:,-:• .e <br /> 6. Transpeoar i Coinpariy Naive U.S. EPA ID Number <br /> t� =;f:+ !1 `,ta•,'3h'tr�isi'+i�nfC 1 3ti r � 1- � itdi: _ _ <br /> 7. Transpoder2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> ER <br /> ( Si': , rzfF?i . t . rift. t :.aC : ta uRe . .. _. <br /> Facility'sPhone;J'56 <br /> ga 9b. U.S. DOT Descr prion (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) <br /> No. Type Quantity WtNol. <br /> 1,i'fif�ti: <br /> O i s rte. lia <br /> w ""? <br /> URI <br /> 2' <br /> to <br /> Rowift <br /> 3. <br /> 4, <br /> 14 Special Handling Instructions and Adeil onal Information <br /> 'L1y' YL1.,7( t' .l:;r' t��'.t:' t17 G Re Ve�&R< Q ..� <br /> H €� a rDi4rt ACTRDRR (•,fit S <br /> IJ ':TIr. F r S �, :t t r!_look 4% Irl n_. 3 ? IFI t 1 ar- ! P F FV"; r . POE. r .. `� a 4? rp <br /> 6'.ra y r <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described aboys by the propershipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 large quantity generator) or (b) (iff am a small quantity generator) is two, <br /> Generatorsl0fferorsPrinted/Type�.Npme It .t ( , *,t � Ott { � Stq{� $ / / Month Day Year <br /> i- 4 ,.`"„` i' 'a-', . ' �. '}'.:-,=.,f-Yr ..at : i C Ro f f _ •i. 'C.......�•.L_: . !^ Re <br /> i '•- tF-i'"J <br /> 16:international Shipments <br /> j.., ❑ import to U.S. ❑ Export from U.S. J Port of entry/exit: <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> Rol <br /> 17. Transporter Acknowledgment ofReceipt ofMaterials <br /> a Transporter 1 PrintedRyped Name ! Signature o :-t% Month, Day Year <br /> CL f ��+ r .J s i.'" ,'•' +' <br /> Z Transporter 2 Printedlryped Name i f Signature r' ' — Month Day Year <br /> 9 <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> Fes., 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J_ <br /> V <br /> L Facility's Phone: <br /> H18c. Signature ofAltemateFacility (or Generator) Month Day Year <br /> a . <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU i. 2. 3. 40 <br /> It i <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature Month Day Year <br /> •. . y. <br /> EPA Farm 8700-22 Rev. 12.17) Previous editions are obsolete. DE it7Ni1 i E[3 FACILITY GOFY <br /> IF YO.0 RECEIVED THIS MANIFEST, YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT. SEE INSTRUCTIONS ON REVERSE SiDE, <br /> i <br /> I <br />