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<br /> RECEIVED BY SJCEHD (EF) on 11/27/2019
<br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) �1 I� Form Approved,OMB No.2050-0039
<br /> UNIFORM HAZARDOUS
<br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number
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<br /> WASTE MANIFESTr•nr r . xr,rrn r r -rc y . rr 008548533 F L E
<br /> 5.Generator's Name and Mailing/Address Generator s Site Address(if different than mailing address)
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<br /> Generator's hone: e,' n rI t ,,_ 170 '4 i ' n r +n, I-n
<br /> 6.Trarsportdt 1TDmpany Name U.S.EPA ID Number
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<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> 8.Designated Fpcility Name and Site Address _ rU.S.EPA tD Number
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<br /> Facility's Plltlh6:Pr+'- na nnrtnnn,r,n� n-
<br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Totalr 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type Ruantity WtJVot.
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<br /> 14.Special Handling Instructions and Additional Information
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<br /> 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,
<br /> marked and labeledlplacarded,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
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> enerator's 0 eras Printed/Typed Name 5ignalure Month Uay Year
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<br /> 16,IntemationakShipments
<br /> L1Import to U.S. ❑Export from U.S. Port of entrylexit:
<br /> = Transporter signature for exports only): Date ieavin U.S.:
<br /> LW 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printed(Typed Name SignatureMonth Day Year
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<br /> Transporter 2 PrintMr Name Signature Month Day . ear"
<br /> 18.Discrepanky I
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑F-11 Rejection
<br /> Manifest Reference Number:
<br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number
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<br /> I Facility's Phone:
<br /> C1 18c.Signature of fdtemate Facility(or Generator) Month Oay Year
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.Designated Facility Owner or Operator:Cerh of receipt of hazardous materials covered by the manifest except as noted in em 18a
<br /> Printedffyped NameI Signature Month Day YearT����t k. ( U • � X__71''
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<br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. a S)G,`�9 i ED FACILITY TO GE tirl:R i CR STATE(iF REQUIT(ED)
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