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ii <br /> Please print or type. _ Form Approved.OMB No,7050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID N,umb r Z Page 1 of 3.Emergency Response Phone d,Manifest Tracking Number 6762 9-7 �1 <br /> t fsl..l?4�94i),�4!�;;;f,61 # Y41 �f rff,"i �tr! '!. KS <br /> WASTE MANIFEST •"se �� <br /> 5.Generator's Name and Mailing Address Generators Silo Address(rfdiffereat than mailing address) <br /> r + :.. t h 21 <br /> ,f a rZ i:) � l.;(1 'a7 4 f�,•�`e=;11f�.—.J... <br /> Genarator'sPhone: `?'j y--ill f <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> 7.Transporter 2 Company Name I U.S.EPA ID Number <br /> t, EAN I N'dIUMa E.I11,t1ZIx�i1'ii�; i�s'Y`t11. SVC; ING. <br /> 8.Designated Facility Name and Site Address U,S.EPA ID Number <br /> C �!c•.lrq (lir if�,;.�rl;J wia'�Itl 1(��"c~ <br /> "if Jon.,,Ole <br /> 1101 9!3,133 <br /> SLti+J3 10 <br /> ��ti`'t5{'L <br /> Facility's Phone; ,ks r a" P <br /> ga. 9b.U.S.DOT Description(including Prope.Sh(pping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WUvoi. <br /> a: i <br /> yDwP 1"p, <br /> 61,.'fir <br /> Z 2. <br /> 3, <br /> I <br /> 4. <br /> 14.Special Handling Instructions andAddillonal inr neat on iVjJ ) . y 6927 4: r X 3:3 79 3 <br /> t;F c:IrI::PEE=;#ti:1J���lr��k��� 1�f,�1_L6IIFiliiil l ,C�+11tr lcrfi r r�i iaf�Fw;? by ��? �x r r h <br /> t, rlc�ipt?1i' S.D fP- si �3eluncp kut 1}.7l'•,it <br /> i r + : <br /> 15.J OE ERATOR' OFFEROR' ER IFI Afil N: erabydec are ihaFihe coriients o ims rxihsignmen are fiilfyan accurate y da'scnbarfa ova byii a proper shipp ng name,a are clas'sifie ,packagetl, " <br /> marked and labeledtplacarded,and are in all dQ spools in proper condition for transport according to applicable international and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I cortify That the conlents of this conslgnm ntconform to the terms of the attached EPA Acknowledgment of Consent: <br /> I cerllty that the waste minimization statement)dardi red in40 CFR26227(a)(if t am targe quantity goneraigr)or(b)•((.f 1 am a small quantity generator)Is true, <br /> enoratq s/OfferoesPrintedrrypedNo a Slgnatui Month Day Year <br /> 16.International Shipments <br /> Ela <br /> Import to U.S. Export from U:S11 Port of enirylo)it: <br /> Transporter signature(for exports only): I bawji)aving U.S.: <br /> of '17.TransporlerAcknovledgment of Receipt of Materials <br /> Transpo Prin(etl/lyped Name 8rgnature_. y Month Day Year <br /> Z Transpo e. 2 finte (Typed Name �, Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quan0 <br /> ty ❑Type ❑Residue tr ] <br /> J Partial Rejection El Full Rojeclio { <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> IL Facilily's Phone: <br /> w 18c.Signature of Alternate Facility(or Gehefator) Month Day Year <br /> I <br /> z <br /> 19.Hazardous Waste Report Management Method Codes{Le„codes for hazardaus.waste treatment,disposal,and fecydfng systems) <br /> rn <br /> 3. <br /> 20.Designated Facility Owner-or Operator:Ceriiflcali n of,ecelpt of hazardous materials covered by the manifest except as noted in Item 188 <br /> Pdntedrrypod Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />