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Please print or type Form Approved,OMB No.2050.0039 <br /> FUNIFORMHA7ARDOUS*ARpOUS 1.Generator ID Number 2.Paged of 3.EmeigencyRas on58 Phone 4.Htariif61TrackingNumbt. tr a � fCc;� , �,re0 SKS <br /> IFEST �}me and l,talifng Address Generator's Site Addrrss(!f digorenl then mailing address) <br /> (� '` S tJ;y 1:€•r I,, 7 i i.11 >,: <br /> Generator's Phone �1 Via""'! •11 <br /> 6.TL otter 1 Co�any,type — <br /> �;i 'PIETY—,,1�Y t,� ��^Y FEN.t 1 t t{ U.S.EPA ID Number <br /> YxW'10008 "J <br /> l>Mrt1;� <br /> 7.Transporier'2 Company Name U.S.EPA ID Number <br /> rFaciliq,'s <br /> dFaclity Name and Site.Address <br /> –77-- <br /> CLEAN 171,4w. 8 SAI%1 f owlr t.r►�+4t i.Cw' <br /> U,S.EPA ID Number <br /> •w W n-, <br /> ne: <br /> r} :1731 T <br /> ga, 9b.U.S.DOUDescdplion(including Props Shloping Nomo„Hazard"Class,ID Number, <br /> HM and Packing Group;(if any)) 10.Containers 11,Tota! 12.Unit <br /> ----.• <br /> No, typo Quantity Wi.Noh 13,Waste Codes <br /> 1, I�ICIhd Ft?t1 Irr"1rt1PSIlJ <br /> (D1-ts,t? ;y r�r,j't{ L.� 'l i 3Y11 $fit, 3 1({a)� 't,,f I7i4 4 <br /> w 2' <br /> 3. <br /> 4, j <br /> i <br /> 14.Spacial Handiing instructions and Additional Info ago <br /> �' fii;t:lzyl .i'c; E} t <br /> i <br /> 1>~r.t. }� f5r r��l gar r�1� ' 1r >:1pnip.y a:,fhiat- i, 1: <br /> 3 - �' �-11 epr• z .t' _ ..s r t,d; s. rt 'r j .z i'.s :(.Lr {` .'.'°r, rift n e-•.�y.` .fid . r3�z <br /> 15, GENERATOR S10FFEROR S CE ifF16ATI0N Phereby declare Ihak the contents of this consignment are fully and accurately do scribed above by the proper shlpp ngna�dassified,packaged;y <br /> marked and labeled/placarded,and are in all res ocis Inproper condition for transport according to applicable international and national governmental regulations.If exportshipment and I am the Primary <br /> Exporter,I certify that the contents of this consighmen conform to the terms of the attached EPAAcknowledg ani of Cons I. <br /> I cadify(hot the waste minimization statement Id ntified in 40 CFR 262,27(a)(it i am a large quantity general or(b)(!I l m small quantity generator)is iius. <br /> onerator's/Offeror's Printedfryped iVam Sf Helot <br /> g Month Day Year <br /> ,� 16.International Shipmonls f�`'`� � <br /> F– ❑impo i to U. . n Export from U.S. rtof entrylaxil: f <br /> z Transporter signature(for exports only): 1 <br /> ,,.Date leaving U.S.: <br /> w 17.Transports Acknowledgment of Receipt of Material <br /> OTrans p r i PrintatllTyped arae Signalule Month JDay Year <br /> CL <br /> zTransporter 2 Prints!Typed Name Signature Month Day Year <br /> F_ <br /> 18.Discrepancy i <br /> 18a.Discrepancy Indication spaceEl Quantity ❑T e f—� <br /> YP l_1 Ros)tluo ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ib Number <br /> ^r <br /> w Facility's Phone: <br /> w i8u.Signature ofAlternate Facility for Generator) Month Day Year <br /> d – <br /> z <br /> 0 19.Hazardous Waste Report Management Method Codes(I.ej,codes tot hazardous.wasto Ireaiment,.disposel,and racycling:syslams) <br /> "41 2 d <br /> 4. <br /> 20.Designated Facility Owneror Operator:Certification ic,re 'Iptof hazardous materials covered by the manifest except as noted in item 183 <br /> Prrnted/Typed Name Signature Month Day Year <br /> I <br /> EPA Form 8700-22(Rev.12-17) Previous editions ate'bsolele, GENERATOR'S INITIAL COPY <br />