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Piease print or type. Y <br /> J Form Approved,OMB No.2{1MO-0039 <br /> UNIFORM HAIAk170U5 1netyr�(] b L:4=y, hp�e q t <br /> WASTE MANIFEST ;,Mfd+�44�i� �« �� <br /> 5.Generator's Name and Mailing Address ,IrH 5 � Generators Site Address(i[different than mailing address} <br /> {rl�tliti <br /> t79l5&-A* e►ro 4 A 74� <br /> Generator's Phone: - '' e y <br /> 6 Transporter 1 Company Name <br /> U.S.£PA Io Number <br /> L etaF17$W. LpmA�r�,d[IC <br /> 7,Transporter 2 Company Name <br /> U3.EPA ID Number <br /> S.LA inaled FNaane and Sita Address U.S.EPA ID Number <br /> hwy ge 11 rmMe eo[1th-yr gEA,7"n r<� Win,Cha; <br /> BEATTY.oft., f3M3 <br /> Fa6lity's Phone- <br /> ga, gb-J,S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 16.Conlainers <br /> HM and Packing Group(it any)} 11.Total 12,Unit <br /> 1. <br /> No Type Ouanfily Wt.NoI. 13 Waste Codes <br /> W 'JN 1210 LVAVTE FLAHILIABLE LKM 3 ,PO . !PPINTIMG tiol <br /> v RELATED t>ATERtALj G� <br /> Z 2. <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Infomnation <br /> 15, GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of fts consignment are Fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> MOked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,f certify that the contents of this consignment oonform 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 /> Genar.pV'wIferoes PrintediTyped Name Signature <br /> 'k th Day Year <br /> J. 16.international Shipments ~ <br /> t=- ❑Import to U.S, n <br /> 9 Transporter signature(for exports unlyy —J Export hom U.S. Port of entrylexiL <br /> 17.Transporter Achnowledqmertt of Receipt of Materials Date leaving U.S.: <br /> a Transporter]FwnJdfTyped.Nam¢ <br /> a <br /> c/— Signature th Day Year <br /> r <br /> n] <br /> M Transporter Printed+T;dp d Name Signature <br /> &Z-A-Ilz Month Day Year <br /> e 18.Discrepancy <br /> 18a.Discrepancy.indicatiorn Space II�� <br /> t_-1 Quantity ❑Type ❑Residue ❑Par[ial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number- <br /> U.S-EPA 10 Number <br /> 11 Facility's Phone: <br /> Ujj 18c.Signature of Altenmate Facility(or Generator) <br /> Q Month Day Year <br /> a <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1 2. 3 <br /> 4. <br /> 2]-Eles gnaled Facility Owner or Operator:Coli ratlon of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> Printedr ryped Name Signature <br /> Month Day Year <br /> EPA Form 8700-22{Rev.12-17} Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />