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Please print or type. <br /> 7 . Generetor ID Number Form Approved. OMB No. 2050-003 <br /> 'P UNIFORM HAZARDOUS Z. Page 1 of 3. Emergency Response Phone 4. ManifestT ack g Nu be <br /> o <br /> WASTE MANIFEST o¢ <br /> (Henerators Name and Mailing '808- ' 5n.- 2J ".�' 1 L E <br /> _ Generators Site Address (if different than mailing address) <br /> ( <br /> it Generators Pho 2 ,;C, mom,{ <br /> 6. Transporter 1 iNompany Name <br /> 77 tt.r- ; .ter -ChefnlA "t;:') T stir; r�r 3._t •11: 7 ;4 p"`: US. EPA ID Number <br /> f 7 Tnunsporeen 2 Company Name <br /> U.S. EPA ID Number <br /> � 8 Designated Faclty Name andSte Address <br /> U.S. EPA ID Number <br /> ( G1 Li :. <br /> I{ Facility's Phone `vw- <br /> [ 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> E <br /> HIM, I and Pack g Group (If any)) 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> No. Type Quantity wt.fvol. <br /> ' ?rt <br /> IN I its <br /> NI IN <br /> 3. <br /> I ) � <br /> r ( 't <br /> ( ti4 <br /> 7 <br /> 14T. special Handlinginstructions and Additional Iom ton <br /> r- �sqeCC OCCUM&N7Z cd <br /> IN IN <br /> i � <br /> p GENERATOR SIOFFEROR'S CERTIFICATION: 1 le eby declare that the contents of this consignmentare fully and accurately described above by the pro : rsh pp ng name and are classified, packaged, <br /> 1 r ( a marked and labeled/plata ded, and are In all respects in groper condition for transport according to applicable International d national governmental regulations. Ifex ortsh' <br /> Exporter I certfy that th contents f this consignment conform to the tens of the attached EPA Acknowledgment of Consent- - ; g P Pmenl and am the Primary <br /> erythat th wastempim zaton statement Identified n40 CFR 262.27(a) (if l am a large quantity generator) or (b) (ifl am a small <br /> quantity generator) Is true. <br /> f ( G e mrs'Offerors Prntedl"yped Name, Signature Month Day Year <br /> d , <br /> { <br /> 16 al OralShipments I / ---_ i INI CZ <br /> ❑ Import to UG. <br /> - Export from U S Palo of e try/exit: <br /> Tr spor' rs gnatu e (f r e„pors only) Date leaving U.S.: <br /> g 17 Transporter Acknowledgment of Receipt of Materials <br /> Trdo <br /> d9 spurtrt r i Printed/Typed Name r <br /> j Sinature Month Day Year <br /> a Vo Tr sP nor 2 Printed/Typed Name ,r f . ' <br /> Ail <br /> Signature <br /> ex Month Day Year <br /> a� il18. epancy <br /> ; 18a DscrApancyindicarion Space <br /> Quantity ❑ Type ❑ Residue ❑ Pertial Rejection <br /> C I f <br /> Dull Rejection <br /> P � i <br /> ' i 18b. Altemala Femllty (or Generetor) Manifest Reference Number: <br /> U.S. EPA ID Number <br /> Oc <br /> Fa T.vs Phone: <br /> POo 18c. SignalLre of Alternate Facility (or Gene alor) <br /> 1p �r Month Day Year <br /> z <br /> E r 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Al P1- 2. 3. <br /> 4. <br /> �2UDesjbnaed Facility Owner or Operator Certica6on of receipt of hazardous materials covered by the manifest except as noted in Item l8a <br /> 1 { Printed�'Typed Name <br /> I" (. Signature <br /> YMontt" DaM;r Year <br /> EPA Form 8700-22 (Rev 12-17) Previous editions are obsolete. — tN IN / 1 <br /> DESIGNATED FACILITY TO GENERATOR <br />