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6 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.G�craterL Number �� 2.Page 1 of 3.Emergency Response Phone 4.ManlfestTracking Number <br /> WASTE MANIFEST 0 01970357.5 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address{if different than mailing ad ross) n ` <br /> Qea2� <br /> Co �r)(, <br /> Generator's Phone_ ��' <br /> S.Transporter 1 Company Name - ro l+� T� U-5,EPA Id Number <br /> 6 <br /> 7-Transport 2 Company Name U.S.EP iQ Nrrmher <br /> 8.laesignated Facility Name and SiteAddrest U.S.EPA ID Number <br /> Facility's Phone. lr <br /> 3a 91b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.CQMai ners 11,Total 12.Unit <br /> 13-Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wf.Nol. <br /> 0 6 <br /> l <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Addit nal nformaiion <br /> 10, <br /> � I�t �aef <br /> 15.GE ERATOW51OFFEROR'S CERTIFICAT N: I hereby declare brat the oontents of this consignment are fully and acrnrately described above by the proper shipping name,and are dasstfied,padaged, <br /> marked and laloe ledlplacarded,and are in all respects in proper condition for transport according to applicable International and 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identl red in 40 CFR 252-27(a)(I[I am a large quantity generator)or(b)(if I am a small quantify generator)Is hue. <br /> 1111 ene o @fteror's Printedayped a Signator Month Day Year <br /> l6.International Shipments <br /> F ❑import to U.S. ❑Export from U-5. Port of entrylexit: _ <br /> Tran sportersignature(for exports only): Date leaving U.S.: <br /> n 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedfryped Name Signature Month Day Year <br /> 11L :Z� <br /> (10Montfr Da Year <br /> Z Transpo r Prin dffyped Name ^ Signature <br /> L4& ► � '' 1 <br /> 18-Discrepancy <br /> 18a.Dlscrepancy Indication Space ❑ Quantity ❑-type ❑Residue ❑Partial Rejection ❑Fuil Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> wr <br /> w <br /> Fad lily's Phone: <br /> ttu 18c.Signature ofAlternata Facility(or Ganerabor) Month Day Year <br /> Q <br /> ]9.H a7ardp us Waste Report Management Method Codes(i.e.,co a for hazard s waste treatmenl,disposal,and recycling systems) <br /> 1 2. 3. 4• <br /> 20.Designated F cilil Owner or Dperator:Certification of receipt of ha rdous terials covered by the manifest except as noted in Item 18a <br /> Printedfrypd Name c Signature u� D2ay <br /> Y <br /> �/J—Z _ f <br /> EPA Form 8700.22(Rev.12-T7) Previous editions are obsolete. f` CESIGNA C FACILITY TO EPA's e-MANIFEST SYSTEM <br />