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Please print or type. } ']k90 ,"151 }ti . `'t `` ?011) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST f::. A j:t is G i)0 Y� r (:i 'i`j )_ 1300) sP- .';7.1,(6 0142-1.6766 f C�E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) �S;rFst;i�ti1i'tidk�fY¢Sfit.I'•4 _ f+l 'tett !L ?} dr4e43 Generator's Phone 0014 fi "14 1 6.Transporter 1 Company Name U.S.EPA ID Number fG=.k't4 tf;b t'tt�'t t, t,�.b71f#t t,3{rn t=;4f iRt t.r}PsFS Yuri;IF a:l. '7 2 r 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number f'°,ift i rrks tf' fi<aitcltx +€iitswr Ile, t Fr,s.cir°arRlr_l,t,!. ..)r1 Facility's Phone: i-if-Ig {C,:a..j ',+iV'D 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. SQA)lk5?'itt`,i4;r'eFt}1 ,sO1,0D 9,(iiiMN(CiiIM,Kt t,Cm= z 2. w 3. 4. i 11.S er Iailr� tHandl{ng Instructions and Additional Information �:,� ti., ;ji�r X11 Itrit! s .Ls1i.Ii�:rti.t i.. ,: �s it �arr�>1 ifPtw: 'in3 i1tl�,Flryi i,,�lf:flcai{tt', ifi r? tu.?.t,'.'`• V-ii"iif for , rt t _t ti t.}_{.ittl,lYi)L .311+;:.�i. .. tt.-£. 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, 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 certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratpeslOfferor's PrintedlTyped Name Signature Month Day Year 1�.-International Shipments ElImport to U.S. ❑Export from-U.S. Port ofentry/exit: ?. Transporter-signature(for exports only): Date leaving U.S.: w17.Transporter Acknowledgment of Receipt of Materials r C2 Transporter 1 PrintedlTypedyName j Signature } Month Day Year O i A Transporter 2 PrititedlTyped Name Signature Month Day Year M 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z .1,9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 i I 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. GENERATOR'S INFIAh COPY t;:-t#tlftatIbti4 ';ILv;tfr? ciL1f?TE Ctrti3lC �1( 1.itid: flit`:�tfl{L�l11(�� sPj;• sf,§T4dk#.±rft3 t?'i4'til+t)k;�l.§I.{,:'1+i'i i2f){buil;.