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Please punt or lype Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 GeneratoQD Nmumbt:r r + ,l 2.Page 1 of 3,Emergency Response Phone 4.Maest Tracking Number WASTE MANIFEST i 2•1 JA 1 2 01 JJ K 5,Genere9or's Nan'e eiid f•!dihng Address clegeratof's Sitq Address(if different than mailing address) A!,;F'h.r.f!(:jet,:_ Vic; S14 I—" 4 . c.nef*oes Phone: r! e! d�e " 0UTSOURCING W U.S.EPAIO.Num; t, 1. 2 .- ? i, 7 Transporter 2.Company Name U.S.EPA 10 Number a- 8,D@(gija)ed,)9bip1yNa6n�aqd°SitE*Q��resgr?. U.S.EPA ID Number Facility's Phone: ga 9b.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(if any)) No. Type Quantity Wil rY . s ¢ LU LU Z W ;i '4 Special Han")irig'lns[Nctiohs`ond,Addibo a In otmatipn : f',:j .. `,�,.i.•�'•, `, 1 .','�'il�.; .,�:,i:�.:' A iii �. '!•.-.` 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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemaffonaland national governmental regulations,If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I pertly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(III am a small quantity generator)is true. Genpra��r9lfaltfe, Fv, Signature Month Day Year 16.International Shipments t— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: w 17,Transporter Acknowledgment of Receipt of Materials Tra I ,•.•l .•.n. yipffd_.. --ame Signature Month Day Year O a Qz Transporter 2 PrintedfTyped Name Signature Month Day Year a 18.Discrepancy I� 18a.Discrepancy Indication Space E-1Quantity ❑Type ❑Residue ❑Partial Rejection Ell Rejection Manifest Reference Number. 18b.Alternale Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature ofAltemate Facility(or Generator) Monih Day Year r— Z 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 12- 3. 4. 20.0esignaled Facllity�Wner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed yped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17)-.Previous editions areobeolAte. • t, GENERATOR'S INITIAL COPY