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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1�Generator ID Number 2.Pa 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST LamC�oo q33 y j 0966 11';�y0020426971 JJ K 5. neralo>a Name and Mailing Address G!till 77,F1 G G L C Generator's Site Address(if different pian niailing address) D,da zs3 q /.yo toss a. 91 I GoD r a4. 1r2 yo Inc. UdT W'6b% o Z 1 7 s 1 3 7 Transporter 2 Company Name U.S.EPA ID Number nd site� AM m�Tr�d )&c-yC4 1 pG U.S.EPA ID Number DOD06W V3 Facllil's Phone: —3 Q S ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. W W 2. 3- 4. I Spedaall Harding Instructions and Additional Information p SILL-0 Lf 15, GENERATORVOFFEROR'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 EPA Acknowledgment 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)(ifI am a small quanlity generator)Is true. Geneaor'sf.Offera2s Prirrted/Typed Name Signaw Month Day Year L--- -4 , l T , a ,,- Z- 7 to 16.Intemalional Shipments P- ❑Import to U.S. ❑Export Ir Port of a exit• ? Transporter signature(for exports only): Date leafing U.S.: X 17.Transporter Acknowledgment of Receipt of Materials LLF Transpqrter 1�P�riVedliyped me 5lgnalure Month Day Year Lel lS e t'i°o /io ZTransporter 2 Printed/Typed Name Signature OG Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑ResidueElPartial Rejection I ❑Full Rejection Manifesl Reference Number. F 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Fadlily's Phone: W 18c.Signature of Allemale Facilily(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling syslems) UJI G 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 Prirnledffyped Name Signature Monlh Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM