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Plea3e print or type.(Form designed for use on elite(12-pitch)typewMer.) Farm Approved.0M13 No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trac Ing Number WASTE MANIFEST z4q 00 F4 892947 J J K 5.Generator's Name and Mailin Address Generator's Site Address(if different than m.5in address) Generatoes Phone: 6.Transporter 1 Company NameU.S.EPA ID Number VO '�- i , �<R w 7.Transporter 2 Cgfnpany Name , U.S.EPA ID Number g.. �vc ' ��'c� ? �`B ' MAR 12 2019 1111 , 1 i 8.Designated Facility Nam an Site Address J U LJ U.S.EPA ID Number er IL L-Irl �'OI Er A�� 5 ,34 Y Facility's Phone: C11119 9a 9b.U.S.DOT Descriptor{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 0 PG 137 r- 2. W 3. 4. 14.Speciat Handling Instructions and Additional Information jEF- B7 ii olr Ppe its r to r poop�e . 0 -7 P--* -� I 0> 1-710 -2.It I 15, GEN ERATOR'SIOFFEROR'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, marked and labeledfplacarded,and are in all respects in proper condkton for transport according 10 applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I cerVy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generator'sfOfferoes Printed/Typed Name Signature Month Day Year -i 16 International Shipments F— ❑Import tds' ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: L% 17,Transporter Acknowledgment of Receipt of Materials a Transporter 1 Printedrfyped Name Signature Month Day Year �d O � - Z Transporter 2 Priniedriyped Name Signature / Month Dag•,.. Yepr, fr 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quartity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.Alternate Facility(or Generator) U.S.EPA ID Number u Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a � Z V519.Hazardous Waste Report Management Method Codes("e,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrfyped Name. Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR