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Please pint or type. 111111111IN1111 Form Approved.OMB No.2050-0039 <br /> s r ID Number Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 7G-"-r,-t'- I b13120790 FLE <br /> WASTE MANIFE -nI �,, � <br /> I 14�71(� lq'7'7 v,1*7,-1[:.�:,,-) <br /> 5.Generators Name and Mailing Address Generates Site Address(if different than mailing address) <br /> V t kiri-:C� Cat <br /> fj r- riViceTIUey S oa 4P j 5 0 i f C A v L,I 11-1'm <br /> nerator's Phone: ^i� t.9.661 Number95�-!l)"' <br /> 6.Transporter 1 Company Name <br /> :r, 1�1j-.,r, I I <br /> 7.Transporter 2 Company Name US!bP�A—1Number <br /> 'A' I.!Y' 9 V� C_;V mr, <br /> 8.Designated Facility Name and Site Addressy ,lf�, yo S. LLC U.S.EPA ID Number <br /> l. -1;h qt re et <br /> FacilitysPhon%l;-'11,1 ny c110 7 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Cordai ersit.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> q i.1 j. G ca Ci`;y- 4 <br /> W Q0010 P <br /> 0 <br /> Z 2. <br /> ul <br /> 3. <br /> 4- <br /> T47-Special Handling instructions and Additional Information i 0902 tSt cit e R e I,111 oft ed i q 11 d <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described�abo 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 n tcrut go I ntal 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 EPAAcknowledgment of Cy". <br /> —I certify,that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or o(if I am� 11 qu eneraXr)is We. <br /> Gen I eslOfferofs PMtedfryped Name Signature <br /> ptl- rp 0 h n f Month Day Year <br /> 1 1 <br /> 16.International ShipmPts 06 25 -J-01 9 <br /> D Import to U.S. ❑Dp-d from U.S. Pon of ejdyoit: <br /> Transporter signature(for exports only): Date(96vin jU.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> a Transporter I Printed/Typed Name Si nature Month Day Year <br /> 0 �icjf L5 <br /> L <br /> M -)I,t;'It, <br /> ZU) <br /> Trans er 2 Printed yped Name Signp Month Day Year <br /> C <br /> 9 _719 <br /> , <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space o.dly OType ❑Residue ❑Partial Rejection 0 Full Rejacii.n <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L) <br /> LL- Facility's Phone: <br /> W 18c.Signature ofAflemate Facility(or Generator) Month Day Year <br /> 0 <br /> i�- 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system) <br /> W 1• <br /> +fi L4 i <br /> Printed/Typed <br /> . <br /> 20.Designated F.CiRy Owner or Operator:Certification of receipt of hazardous materials covered by N manifest except as noted in Item 18a <br /> t yp <br /> ed Name Signature Month Day Yea, <br /> kaWLA "' .� WCA11O& I I I, <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obs-5.1ete: <br /> 0 DCF JMVD FACILITY TO EPA's e-MANIFEST SYSTEM <br />