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Please print or type, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 r for ID Number 2.Page 1 of 3.Emergency Response Phone4.ManiiesI.Tracking Number <br /> WASTE MANIFEST Z Y7 1 I +�ell?f yG 020426970 JJ K <br /> 5. erieralors Na da I�`'! SG ��/C I—L C GenemtVs Site Address(if different Ihan maipng address) <br /> Coo 1 <br /> ceiarator'st;nope: o�S�G�-Yfl7 .Q l C4• 4?2s�/D <br /> �� W, f9 � 1 7 5 1 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> J <br /> 8 4JJJWName and Site Address U.S.EPA ID Number <br /> 63M-gh314 11 Dr <br /> ;Kerms C Ilii 64129 <br /> Facilitys Phone: 816 924-5114 M O D '9 8 1 1 2 3 3 9 1 <br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> r rLLI <br /> � - <br /> LU <br /> 2.U►c�1�4 i �ji�1Y� ►kG� <br /> y- ��Os 3 �c 6"474-, 1 � g' <br /> �o►C A� /,-/0 5,�KcfAP AV,W5L0f- ,� � �� � �- <br /> 4. <br /> 14.Special Handling instruclJorna and Additional Information <br /> 1 PAM LIQot 0 PPL CoAAA- LIPO -5U_630X1S <br /> 2 rcieft, ZJ P SL.L—n t C, ti:�o7�`i7�-1 <br /> 15. GENERATOR'SIOFFEROR'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, <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 or(h)(if I am a small quantity generator)is true. <br /> GenetAlorslOffarofs Printed+Typed flame Signal nth ply Year <br /> G 'p <br /> _J 16.IntamstionalShipments <br /> H ❑Import to U.S. ❑Expo 5. Port of a lexil: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> Ir 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter Prtntedffyped Na Signature Month Day ''Yea``r,, <br /> o } 1/0 2c) <br /> tS r r,e <br /> Transporter 2 Printedrfyped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> � 18b.Aflemate Fadfity(or Generator) Manifest Reference Number. <br /> J <br /> U.S.EPA ID Number <br /> U <br /> LL Facillty's Phone: <br /> w 18c.Signature of Altemate Facilily(or Generalor) <br /> a <br /> Z <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 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 /> Print yped Name signature Month Day Year <br /> EPA Farm 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />