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.e t <br /> Please p Form Approved.OMB No.2050.0039 <br /> 1 Generator ID Number 2.Page 1 of 3.Eme 9 Response Phone 4.Manifest Tracking Number <br /> U�IIFQ�II�AAZARDOUS ��R�? eJK <br /> p®WASTE MANIFEST CF 9.ut tz> a t '0 �y�` 7 1,`�`._= 020870235J <br /> JK <br /> Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> /rmIDES 9dk` Ira OSArf" S'A G1 LD1:1S I L <br /> Generator's Phone: a24- €=4'`4 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i-'1AC1FiC V�rrfjLlriRt,l :I (<rlrt°E Fi ` :� I i�t;�.'j <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> @t�t"Ir sC �+'f:.S[slte`t �" 7 ECQ,1,iER1r SERVICE; <br /> Facility's Phone: ft0CT.' '/f 9 -.`r 17t <br /> '9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM 's and Packing Group(if any)) No. Type Quantity Wt.Noi. <br /> Z <br /> ,t .t' r`R t _,ft L M11 t:.+'i` f t.. ' t+t<,' 8 W-Y LU p <br /> B:Ik °i t 2 t k.".Ex��� <br /> 4. <br /> 14.Special Handling Instructions and Additional Information a+;!°t tp ul <br /> .r. <br /> B .tf'i' `f` jf t i.-I i f f> - !i#� X11. � C:l' 'i #:��t�1T E'l I i r p�E wrlt."l�E:wu' <br /> -41b� t $ � �, $ il (P Ili I1 1I 11 #1#i <br /> TPr0tS 'I:)t`1FP 1 Pt$t:UC 0 1 rtj . 2 fa <br /> 15. GENERATOR'S/OFFEROR'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 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. r <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b),(ifI am a pp quantity generator)Is true. <br /> Gen ator' 'Tp Printed(f'y ed Name Sign r , <br /> 1 Month. Day Year <br /> 16.International Shipments �W <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/fyoed(J� Signature rr % ( Month; Day Year <br /> 4.r <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space e <br /> Quantity ❑Type ❑Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number a <br /> J <br /> V <br /> u FacilitysPhone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />