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Please Print or type- <br /> UNIFORM J <br /> H 47ARQ 1.Generator t <br /> D135 D Numb <br /> er <br /> WASTE MANfFEST 2•page T of 3 Emergency Response Phone C Manifest Tracking Numpetoved•OMB No-2050-00. <br /> 5-Generator's Name and Mailing Address 0 14902925 <br /> r4���� ;C] <br /> Generator's Site Address(if different than malting address) 2! F L E <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name <br /> 7-Transporter 2 Company Name U-S.EPA Ib Number <br /> 8-Designated Facility Name and Site Address U 5•EPA i0 Number <br /> VS.EPA ID Number <br /> Facili s Phone: <br /> 9a. 9b-U.5-DOT Descr plipn{including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group[if any)} <br /> t, 1p.Containers <br /> a P1.Total 12,Unit <br /> dNo- Type ouantity Wt.Nol- f3-Waste codes <br /> LU <br /> 2LU <br /> —` - <br /> 3, <br /> r <br /> 4. <br /> i <br /> 14-Special Handling lnstruclions and Additional information - <br /> GEryed and 1pbS1edl.1 ded CndaI a in all re t hereby declare that the eontents of this con11 signm11 ent ora lofty and accurately deser6ed <br /> marked and labetedlplauarded-ond are in all respects in proper conditon for trans <br /> Exporter,I oertrfy that the contents of this Port accordin to a above, the <br /> I oerti y that the waste minimization statemenl rdenlifreconf"I'm 10 the d in qQ 62"Of'me attached EPA ppli�ale iniemationaland natio y r shipping name,a d are cRassifred, <br /> Gen tar slOfferors Printed7T Aty"Oedgrnent of Consent. vemmen lotions-li ex packaged, <br /> Yped Name {a)[f 1 am a large quantity generator]w[b][ill am mall port shipment and 1 am the Primary <br /> 6 Signature RY <br /> =.j 18-international Shipme Month Day Year <br /> H <br /> S Transporter signature for exports only):�Import to U-5. <br /> IX 17-Trans Export from U-s- Port of n lexit: <br /> porterAckno1l mant of Receipt of Materials <br /> ix Transporter 1 Printedrf Date ng U.S.: <br /> Q reed Name <br /> rq Si afore <br /> 2t Transporter -Prfnted/Typ&d Name <br /> Month DaY Year <br /> S gna[ure <br /> P8.Discrepancy <br /> Month i]a <br /> 18a•Discrepancy tndica;ian Space <br /> ❑Ruantity y Year <br /> Q Type ❑Res due t� <br /> l�l <br /> P86..4tternate Facility(or Generator) Partial Rejection i�Full Rejection <br /> U' Manifest Reference Number; <br /> Faclltiy's Phone: VS-EPA tO Number <br /> LU 18c.Signature of Alternate Facility� ty{or Generatory <br /> 2 <br /> 65 <br /> 19.Hazardous Waste ReNrt Management Method Codes i Month <br /> Day Year <br /> i- 2 {e codes for hazardous waste FreaVnenl.disposal,and recycling systems) <br /> 3- <br /> 20.Designated Facility(owner oro 4. <br /> Pr' tedlT 17era[cr;Certificat an of receipl of hazardous materials co <br /> d Name � +erect by the manifest ex <br /> pt as cted in item 180 <br /> Signature <br /> EPR F ' 8700-22(Rev.12-17) re <br /> v;ouS editions are absolefe. w <br /> th 02 Year <br /> DESIGNATED FACILITY EPA's e�MANIFEST SYSTEM <br />