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Please print or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 0r' 3�.eEmergency Response Phone 4.Manifest Tracking Number WASTE MAN "17419 16 ` V� L"Z�}��"S�p 019703609 J J K �erato's_ j Name an`Mia lire Address Generator �s Site Address(if T n mailing address) l� I OESv Gw-� n %-b Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number -VIA�Ci�.�+ �tyy�C1�.)N1�iJr SG /1�-�'S L <-1-At-b o5� 7.Tran orter 2 Company Name U.S. PAID Number 8.Designated Facility Na a and Sil Address U.S.EPA ID Number C-c�tti� al¢R-toN `l c,9 C-)V"I _ Facility's Phone: 93. 9b.U.S.DOT Description(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./Vol. w 2. W 4. 14.Special Handling Instructions and Additional Information t X59 b-4- Zp -Z- 15. GENERATOR'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 labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 sII quantity generator)is true. GeneratoeslOfferoes Printed/Typed Name {� Signaha I Month Day hYear 16.International Shipments F ❑Import to U.S. ❑Export from U.S. PoQentyAt:_ ? Transporter signature(for exports only): -- DaS.: ry 17.Transporter Acknowledgment of Receipt of Materials O Transporter 1 Printed/Typed Name "'� �� Signa ore � Month Day Year 74– Trans r 2 Pdntedrryped Name Sign tore Month Day Year I 011 18.Discrepancy I 1 I __ 18a.Discrepancy Indication Space Quantity ElTypeLJ Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U S.EPA ID Number Ci IFacility's Phone: Ltj 18c.Signature of Alternate Facility(or Generator) Month Day I Year N19.Hazardou Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) — _– Q 1. 20.Designated Facility Owner or Operator.Certification of receipt of hazarogus materials covered by the manifest except as noted in Item 18a Prim d/Typed N 6.�( rSignatureMonth D EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MA (FEST SYSTEM