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Please pant or type Form Approved OMB No 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 or 1 3 Emergency Response one d.ManifestTracking Number WASTE MANIFEST FLE S 5 Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transperter 1 Company Name 1J EPAID Number 7 Transporter 2 Company Name U S EPA Q Number 8 Designaled Faulty Name and Site Address US EPA ID Number Faa s Phone: 9a, 9b U S DOT Description(including Proper Shipping Name,Hazard Class,ID Numb,r, 10 Conlainers 11 Total 12 Unit HM and Packing Group(if any)) No Type Quantity Wt Not 13.Waste Codes occ I � a z 2 w c� 3 4 —� 14 Special Hatmtl nq 1wi ncC lltlrr5 and Addlii Taal Infi rn.iln• 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 internationaland 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 EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262 27(a),'I am a large quantity generator)or(b) w:a small quanty generator)is true Geherltnrs 0tfnro's Arintedflfyped Name. f r&M Day Year O$ 1,411 lb, _J t6 tntamalinnal5h:pm r ❑Import to U S Export from U S Port of enlry/ex h z sransperle+Sig nah,re filar oxportsgnty)- Date leavnq U S W 17 Transporter Acknowledgment of Receipt of Materials LU liaresporlm 1 PhnW'TypBd Name Signature PAnnlh Day roar O o 2d Z Transporter 2PrinledilTypedName Signature Month Day Yrar 18 Discrepancy 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection IM;krL*,c{Reference Number- r 1Sb Afierrrale Foci q(or Generat(r) US EPA ID Number J U rarlrty's Phone: W 1 Be Signature of Alternate FacTity(or Geriera!or) Month ay Year a z 19 Hazardous Waste Report Management Method Codes(i e,codes for hazardous waste treatment,disposal.and recycling systems) NJ 1 2 4 20 Designated Facility Owner or Operator Certification of receipt of hazardous maleriais covered by the manifest except as noted in Item 18a Pnnl VPgd llanu! inTn;liur4 r,4;y11h Dny fear EPA Form 8700-22(Rev 12-17) Previous editions are obsolete.