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Please print or type. <br /> UNIFORM HAZARDOUS 1.Generator ID Number Z.Page 1 of 3.Emergency ReForm Approved.OMB No.2050-0039 <br /> sponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and MailinO 13 55951 F L E <br /> g Address <br /> Generator's Site Address(if different than mailing address) <br /> I <br /> Generator's Phone:6.Transporter 1 Company Name <br /> / /� <br /> AU.S-EPq ID Number <br /> I") 7.Transporter 2 Company00 Name <br /> U-S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> t No. Type Quantity Wtji/al. 13.Waste Codes <br /> 4� <br /> W 2' t <br /> 3. 1117 <br /> i <br /> ( 1 <br /> t <br /> i <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOWS/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 intemaiionaland 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 C ent. <br /> I certify that the waste minimization state e 'entified in 40 CFR 262.27(a)(if I am a large quantity generator)or (ifl m a small uanti' er or)is true. <br /> Gen rata( eros Printed!_ p Name <br /> Month Day Year <br /> 16.International Shipments <br /> f <br /> Import to U.S. ❑Export from U-S. Port of entry/exit: <br /> ? Transporter signature(for exports only): <br /> IX <br /> W 17.Transporter Acknowledgment of Receipt of Materials Date leaving U.S.: <br /> � <br /> Transporter 1 P.in Name <br /> O Sl^natur <br /> a / fvtonth Day Year <br /> z Transporter 2 Printedfryped Name <br /> icnalur2 <br /> F Month Day jYea <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity a T„^= <br /> ❑Residue ❑Partial Rejection <br /> El Full Rejection <br /> H 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> J <br /> V U.S.EPA ID Number <br /> LL FaciliysPhone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> V5Z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,ana recycling systems) <br /> yl2 3. <br /> 20.Designated Facility Owner or Operate <br /> Printed/Typed Name r:Certification of receipt of hazardous materials covered by the manifest e s noted in Ite <br /> ignature <br /> ffc& l <br /> i ✓ >'' Mor Day Year <br /> EPA Form 6700-22(Rev.12.17) Previous editions are obsolete. <br /> a E n1 FACT T TO EPL,' a �i4�°If ES SYSTEM <br />