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n, t 1-/ C) 2D Please print or type. Y F' Form Approved,0 'B No.2050.0039 �• UNIFORM HAZARDOUS 1.Generator ID Number 7 �'J 2.Page)of 3 Emergency� rR�pons�P�n�� 4.Manifest >a.Trkang Number ��, I WASTE MANIFEST tp rr)' l t� / Z ,b J _ — - �...f ,,, Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone 6,Transpprter 1 Compa y Name ! U.S.EPA AIID)Number � `��, '�- 7.Transporter 2 Company Name U.S.EPA ID Number 8.D sig ated Facili Name and to Addre" U.S,EPA ID Number Facility's Phone: /l 7�, -7 9a• 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)) No. Type Quantity Wt.Nol. 13.Waste Codes o ,. pip Z 2. W 3. 1 4. r I 4.Speci I Handling InstructionsandAd itional Information 15. GENERA70 ' 10� EROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratety 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 ceptifylhat.the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) 'Yam a small quantity generator)is true. 5pnKr.tor`sjQIferr67s Prntedyped Name ` Signatur J; —- /f Month Day Year 16.Intemati gnal Shiprh6nts �� ~ j.., ❑Import to U.S. ❑Export from✓t1.S, Port of entry/exit: ' ? Transportp4ignature(for exports only): Date leaving U.S.: W 17:fifansporterftnowledgment of Receipt of Materials Tra\{rsp/oyrter 1 Prin ed/rryp Name f Signe re Month Day Year � Qp fA G•L"/tGX { Transporter 2 PrintedfTyped Name Si ature Month Day Year 18.Discrepancy .r 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V W Facility's Phone: C3 I 18c.Signature of Alternate Facility(or Generator) Month Day Year 1 . 1Q Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU, 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 Printedflyped Nacre P Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, DESIGNATED FACIL.ITYTO GENERATOR