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Please print or type . (Form designed for use on elite ( 12-pitch) typewriter.) Form Approved . OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number F6 RR�� WASTE MANIFEST ' 0 , fi : I I , ; ; ;i t Je� 6 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) I Generator's Phone: 6 . Transporter 1 Company Name U.S. EPA ID Number � riNMlIVTAI . `+FI>,'Vlt?F.'� 7. Transporter 2 Company Name U .S. EPA ID Number (::t Rd SYSI'E•'M INt, . ( A H It t,) (? .i "i Ci A f; 8. Designated Facility Name and Site Address U.S. EPA ID Number Pik Z t$ ( ih1 ' .� . 1114 •' 1. i Facility's Phone: 3',7R i " ;•'s= 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 Wt.Nol. ®LU � ' i 2' i- ECEIVED 3. 1 AIJK 0 3 2019 4. ENVIRONMENTAL j HEF.I TH DEPA.RTMFNr -- _ 14. Special Handling Instructions and Additional Information (vit! t . r i . j1 +�`r t, f7 �4 ( %il3I f ,' to l ) i t' i.1 ; tttt)(1r9fd- i,1t WtlliiTFFtI IPld� l . ' f1F. tf_ :. t 1 h1AF . fitt'fitottE : 17' i * F'ht: FII. FAt9t1:1. : i t; x+i ? 'ds112r) tiAl.tB*i J . PAPfft f1LTE' Ni ' 'r APPRR+JPR).ATF PPE EX UIPMEN T ? r 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and 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 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity,generator) is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year mr 16. International Shipments ❑ Import to U .S. ❑ Export from U .S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S. : 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year en ZTransporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejectionj ❑ Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U .S. EPA ID Number c� Facility's Phone: LU 18c. Signature of Alternate Facility (or Generator) Month Day Year B 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ® 1 . 2, 3, 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete . GENERATOR'S INITIAL COPY