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Please print or Type. Form Approved.CMB No.2050-0039 UNIFORM HAZARDOUS L Generator ID Number 2.jap�1,o .3,Emergency Response Phone 4,Manifest Tracfting Number WASTE MANIFEST t jt0jj7 € _4 `, e �•. JJ 5.GeneraWs Name and Mailing Address Genera)r'S:to d s {f rfferentthan ailln.addressy Generator's Phone:' 6.Transporter 1 Company Name U-S.EPA fA Number 7.Transporter 2 Company Name U.S.EPA ID Number 8. es rated Fari'ity Name and Site Address U.S.EPA ID number Facility's Phone: . ga. 96.U.S.f1OT Descri ption[including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unt HM and Packing Group(if any}} 93.Waste Codes No, Type Quantity Wt.Nol. lit 1. ul R', Z 2. LLJ 3. 14.$pecial Handling lnstcuctions and Additional Information Milo• 8't "N CA to boat 15. GEN ERATOR'S10FFER0R'S CERTIFICATION; i hereby declare that the contents of this consignment are hilly and accurately described above by the proper shipping name,and are cfassftd,packaged, marked and Iabetedlplacarded,and are in all respects in proper condition for transport according to applicable Internationa and national governmental regulations.If export shipment and I am the Primary ExpoRer,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledg meat of Consent. I cerfify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or{by(if I am a small quantity;generator)is true. General s?Offeror's Printed,'Typed Nine Signature ,'-x Month Day Year A _.......�..�.,� r '16,international Shipments ❑ J impart to U.5- ElExport from U.S. Port of entrylexit: Transporter signature fforexperts cn[yy: Date leaving U.S.: 1X 17.Transporter Acknowledgment of Receipt of Materials Lu Transporter 9 Printed.-Typed Name Signature Month Day Year Cg a Transporter 2 Printed,Typed Name Signature Month Day Year H 18,Discrepancy 18a.Discrepancy Indication Space puantfty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest.Reference Number: 18b.Alternate Facility(cr Generator) U.S.EPA ID Number J_ E.3 I Facility's Phone: w 18c.Signature ofAlfernate Facility(or Generator) Month Day Year Q 49-Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ln�etnwnt,disposal.and recycling systems) 1- p ) 2. 3. 4- 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials coverc-d by the niapi€est except as noted in Item 1 B Printed-Typed.Name _ r Signatu !M Month Day Year rr� ="R .1._i.�. � •8 y r:'uf�a�.• ..ri'•r' Y - -..�,.'�� '1 � EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. TRANSPORTER COPY