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m W -u00 <br /> v m = VO <br /> N <br /> 7 -0 v <br /> W cD O N G1 <br /> TI <. OWN <br /> p O (0O <br /> C co CD <br /> M. <br /> _.. O <br /> 3 Cil <br /> HAZARDOUS 1.Gerrera1or 117Number �Ilu'� � N <br /> MANIFEST 2.Page 1al vEmargerlcy Realbnse Phpre 1 <br /> GeManMast7 I—Appmre.0.OMBNo!f,:.--. (� <br /> N's Name and Maamg Atldre�s x13120861 F Gal ,. L E i ooj <br /> AtldRas flf dAlnarn�^'meq d�m,l <br /> Glarknal ph_ <br /> 6 TmnSpener 1 Company Name - 3 <br /> IJ S EPA ID Momper � <br /> 7.TranSponer 2 Company Name <br /> 8.Designated FaciliN Name an0 U 5 EPA ID Nlnnber <br /> Sde Address <br /> 'J$EPs G N,mrF. QJ <br /> Facial's ph— CIS <br /> i�. 9a. 96.U.S.DOT Description(including Proper Shipping Name,Haza+d Class.ID Number. O <br /> Hand Packing M Grca,o pfanyl) 10 Gonuiners 0 <br /> J ..3 11 War •- <br /> Type ol,amiry Vf'�• yfdsle Grns O <br /> K Z) <br /> z <br /> 19.Special Handling lnslmgiorls and Additional lntear lion ' <br /> r ----------------- <br /> ]5. GENERATOR'SlOFFEit:Ir:CERTIFICATfON:Thereby declare that the contents vl kis consignmenl are fully antl accurate)desedbed <br /> j marked and labele at hngacopte and are in all respects in proper wndilion for transport according to applicable intemaM1onaland national goremmentalhregulale if export shi <br /> Exporter,IcerGfy that Ute contents of this consignmedconform to the terms oflhe attached EPA Acknowledgment of Corsent- y �� � e� <br /> cerOfy that the waste minimlza0dn Statement idanti5ed in 40 CFR �t and 1-She P,vr, <br /> Generafors1011eror's PrintetlRyped Name 262,27[x)if I am a large quanfry generalorl or(b)(dl am a small <br /> i <br /> Signature quantity gerreralerlufie. <br /> ..� I IIIA Oar <br /> e 16.Intemai,mal Shipments <br /> ❑Impart to U S <br /> L ? Transporter Signalure(for expans only): ❑Export Imin U.S. ?Orta:enirr:exil: <br /> t <br /> o w 17.TranspoderAchnowledgmenlof Receipt of Materials bate:eacmg U.S.-�' ---- <br /> 2 Transporter 1 printedTyped Name <br /> a a SignaWre <br /> Q 'NI°'''^ J} Tea- <br /> d' Transponer2 PrfntedlTyped Name <br /> Signature <br /> H � <br /> 18.Discrepancy <br /> 18x.Olsorepancy Indrea6on Space <br /> ❑Ouanliiy ❑Type <br /> 1 ❑Residue ❑Pal Reie hon <br /> .�FW Refect <br /> LL H I 8.Allemate Fac jjjy(or Manifest Reference Number. <br /> w U U.S.EPAIp Number <br /> LL.Facility's Phone: <br /> y W 181,SigoalureorAllamate Facility for Generatory <br /> W Q <br /> 7 Z Mcnlh Y `rear <br /> 19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment.disposal,and recycling systemsf <br /> wt <br /> n 2 3. <br /> 20 Dealgnated Facility Owner or Operator Cegrfc tion ofreceipt of haZaMdus maleriala rovered by the m8iri fest Skeletal III noted m IS.161 <br /> f Pnnledi'Typed Name <br /> SignaWre <br /> M,.M eat 1H+r -0 00 <br /> EPA Form 8700-22(Rev.12.17)Previous ediliona are o6solela. D Q <br /> GENERATOR'S INITIAL COPY <br /> � 2 � <br /> (D N <br /> CD Zl <br /> CIO o <br /> O <br /> W <br /> N v <br /> U1 (D v <br />