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Please print or type. <br /> UNIFORM HAZARDOUS 1.Generator ID Number <br /> WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone 4.Man t reckin Drm N cob; MH No.2050-0939 <br /> '12'1 �� 2 <br /> 5.Generator's Name and Mailing Address �`�' �/ f r FLE <br /> rc r�.y �s � GerMra(ofs Si(e re (if digerent tlin mail...adtlress. <br /> Generato/s phone; r <br /> 6.Transporter i Company Name <br /> / U.S.EPA ID Number <br /> 7 - ' r- ^ /, <br /> 7.Transporter Company Name r f ' •� � ,� _ <br /> . 41 / ,1 / <br /> U.S.EPA Number J <br /> Migrated Facility Name an Site Address <br /> ,., - ,J <br /> 5^ /rJ / U.S.EPA ID Number <br /> 7 <br /> ga. 9b.U.S.DOT Description(Including Proper Stripping Name,Hazard Class,ID Number, r U <br /> HM andPacking Group(:(any)) 10.Containers 11.Total 12.Unit / <br /> No. Type Quantity WLN01. 13.Waste Codes <br /> W <br /> z 2. <br /> W <br /> d•J <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional lnfonnation 1 <br /> ! L/r f r et-- /c, <br /> ! '12� /" / <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declamhatmecontentsofthisconsgnmentare fully and accurately described aboWb <br /> i <br /> marked and labeled/placerded.and are in all respects in proper condition for Vanspon according to applicable international and national governments a proper shipping name,and are classified,packaged, <br /> Exporter,I certify that the contents of this consignment conform to the(amts of me attached EPAAcknowiedgment of Consent. g regulations.If export shipment and I am the Primary <br /> I cerey that the waste minimization statement Identified in 40 CFR 262.27(a)(g I am a large quantity generator Or gl am a small quantity IYL <br /> Genennors/OReror's PnntedRyped Name ) O( q My general r)is true. <br /> r Signffiure Month Day Year <br /> =j16.Inlemadonal Shipments <br /> Z Transporter signature(for exports only): <br /> to U.S. ❑Export from U.S. Port of entry/exit: ' <br /> CC 17.TmnsporterAckmWedgment of Receipt of Materials Date leaving U.S.: <br /> Transporter 1 Pdnted/Typed Name <br /> Qc <br /> 0 Signature <br /> - - Month Day Year <br /> zz Transporter 2 PrintedfTyperl Name Signature <br /> F Month Day Year <br /> f. 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type F-1 Residue El <br /> Partial Rejectlon ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Man'rfest Reference Number: <br /> U. .EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w 18c.SignaNre of Aaemate Fadlby(or Generator) <br /> z Month Day Year <br /> 19.Hazardous Was1e Report Management Method Codes(i.e.,codes for hazardous Waste treatrnenk dis sal,aM <br /> 0 1 z po recyding systems) <br /> 3. 4 <br /> 1 20 Designs ed Facili y Ownar or Ope a o CeNfication of receipt of hazardous materials covered by the manifest except as ncled in Item 18a <br /> Printed/Typed Name <br /> Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />