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l�� <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS [1.Generator ID Number 2.Page 1 o 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '-'! -�. I . - =013120792 FLE <br /> 5.Generators Name and M—ailing Address Generators <br /> Site Address(if different than mailing address) <br /> 7 i- <br /> Generators Phone: <br /> 6.Transporter 1 Company Name <br /> U.S EPA IDNumber <br /> — <br /> TTransporter 2 Company Name <br /> U.S.EPA 18 Number <br /> B.Designated Facility Name and Site Adrr.;S- U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a. 9b U.S.DOT Descnption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) No. 11.Total 12.Unit 13.Waste Codes <br /> Type Quantity Wt.Nol. <br /> 0 <br /> 2. <br /> LLI <br /> 3. <br /> 4. <br /> 14.SpecialHandling instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by p per 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 governme I 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 Cop6nj <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator',or(b)XI am small quaqllrVnerator) true. <br /> Gener tors/Offeroes Printed[Typed Name <br /> ror <br /> Signature—`, Month :Day Year <br /> `3r <br /> _j 16.International Shipm <br /> F— 11 Import to U.S. ❑Export from U.S. Port of entry/exit:9 Transporter signature(for exports only): Date leavr96 U-S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> UJ — <br /> 0 <br /> Transporter 1 vnnted/I yped Name <br /> ]Sign:use <br /> - Month Day Year <br /> Z0- <br /> cn <br /> Transporter 2 Printed/Typed Name <br /> < Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 181h.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> J <br /> L) <br /> Facility's Phone: <br /> Signature ofAltemate Facility acility(or Generator) <br /> Month Day Year <br /> 0 <br /> C— 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> — <br /> LLI i <br /> 0 3 <br /> 12 <br /> 4. <br /> 20 Designate . <br /> d Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted Item I 9a <br /> ' <br /> 'M�i <br /> Printed[Type- <br /> a Name <br /> 0 Signature Month D� <br /> EPA Form 8700 7.L <br /> -22(Rev.12-17) Previous editions are obsolete' <br /> 7, <br />