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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Ge tar ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Traeking Naml�ar <br /> WASTE MANIFEST 413,99711 ge`&/Y/3?Yo 020427506 JJ K <br /> 5.G narala> Name Mai Ar�ess l r �� ��� �� Lkn�tops Site Address{t diftetenl than mailing address) <br /> 0. <br /> `• . 1 q0? 193a/ 04. ��Y® <br /> Generators Phone. h -91A . � I,�S F� r� <br /> Inc. '3.-r FiA�Nll 16 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> d Si <br /> V124AW XZC,rGG'A�04 (,.(„C U.S.EPA ID Number <br /> FacFlity's Phos . - T T <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12. <br /> HM and Packing Group(it any)) No. Type Quantity Wt.Unit Unit 13.Waste Codes <br /> o (JNl-7-2Q IW A-!rIA-cu, lbrt Dt 9, 3 QJL3 <br /> Z 2. <br /> W <br /> 3. <br /> +I, <br /> 1 .5pectal Handling Insirucl0s andAdditio I Infor?Z' <br /> 15, GE <br /> NHRA70R'S10FFER0R'S CERTIFICAVIDN: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b)(ifI am a small quantity generator)is true. <br /> Generalor roc's Prinfedff'gped Name Signatura Month pay Year <br /> •j 16.Intemalionaf Shipments <br /> F_ ❑Import to U.S. ❑Export f S. Port of irylexit: <br /> z Transporter signalure(for exports only): <br /> Date leaving U.S.: <br /> 17.Transposer nowk4ment of Receipt of Materials <br /> ii Trans po Print N mer 41*7 <br /> � Signa Month Day Year <br /> a J■ 7 <br /> IL <br /> Transparfar2 Printedffyped Name )lure Month Day Year <br /> 18.Disciepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> _J <br /> V <br /> LL Faeilitys Phone: <br /> W 18c.S gnalure of Alternate Facility(or Generalar) Morich Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU C3 1 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> RAN edffyped Name Stgnalure Monlh Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />