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Please print or type. (Foran designed for use on elite (12-pitch) types V ' r Form Approved, OMB Na . 2050-0039 <br /> UNIFORM HAZARDOUS I ' , Generator ID Number Manifest Tracking Number <br /> WASTE MANIFEST � a I „ a? V1 2 JJ K <br /> 5. Genere.Ws Name and MaifngA&nsss i' ` ng address; <br /> aID <br /> Generator's Phone: '. <br /> B. Transporter 1 Company Name. U .S. EPA ID Number <br /> : 0,,;i, 7 2019 <br /> 7. Transpow 2 Company .Name U.S. EPA ID Numbw <br /> B. Designated Facility Narne and She Address U.S. EPAI D r <br /> DEPARTMENT <br /> Facility's Pnone: <br /> ga 9b. U.S. DOTDescriptlon iio oludng Proper Slipping Name, Flazard Class, ID Ntartber, 10. Containers 11 , Total 12, Unit 13, Waste Codes <br /> HM and PaekngG•oup !Wany)) No. TYPE Ouandry WtNol. gg <br /> LLJ <br /> 3. MAR 27/ (11 <br /> i <br /> 4* ENVIHONMENTA ). Al J <br /> i <br /> DFPARTrUn• <br /> 14. SpOal Handling Insductlons ano Additional nforn3tion <br /> 15, GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the eontems of this oonslgnmenf are fuly and accurately described at-ova by the proper shipping name, and are dassIned, packaged, <br /> marked and I"adfplaoarded, and are in al respects in proper condition for transport ay.;ording to applicable iiternationaland net'onal gove•nmental regulations. If exportshipmsnt and I am 'he Primary <br /> Exporter, I cantly that the contents of this consignment conform to the terms of the attached EPAAUcncw(edgmsnt of Consent, <br /> I certify the; the waste mi irrdzelion statement klent&d In 40 CFR 262,27 la) (If I am a large quantity generator) or (b) (ff I am a smal quan*/ genereter) is true, <br /> Gensrator'sK)fferoes PrhdedTTyped Name Signature Month Day Year <br /> J 16, InternWand Shipments <br /> F- ❑ Import to U. S. ❑ Expot from U .S . Port of entry/ext: <br /> z Transportersignattre (fop exports only): Date leaving U.S.: <br /> w 17. TransporuerAcrnowfeigmentofReceiptofMaterials <br /> O Transporter 0 PdntedTyped Name Signature <br /> Month Day Year <br /> d <br /> ZZ Transporter2 Rdhiadrryped Name Signature Mcnih Day Year <br /> r- <br /> 18. Discrepancy <br /> 18a, Discrepancy Ind cation Space ❑ Quantity ❑ T e ❑ <br /> } }p ❑ Residu'e Partial Rgeclion ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b . Allernate, Facility (or Genarator) U.S. EPA ID Number <br /> _J <br /> V <br /> W< FacfivsPhone : <br /> w18c. Signattas ofAltamata Facility (or Generator) <br /> a Month Day Year <br /> z <br /> 19. Hazardous Vtaste Re Dr, Man ement Method Codes ;i.e., codes for hazardous waste treatment, disposal, and <br /> P a9 pose , recycling systems) <br /> 0 T 2. 3. 4 . <br /> 20. Cesgnated Facility Owner ,or 0perstor. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Frintedfryped Name SignaVe Month Day Year <br /> EPA Form 8700.22 (Rev. US) Previous editions are obsolete, G = NERAFOR' S IN1€1AL COPY <br /> d £64Z6b660Z IS91 d69 : ZL ' 6L LZJeN <br /> L <br />