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SH NV_LIVO Nosvr s- <br />1 <br />irk Lek <br />ufi <br />(D <br />0 <br />0. <br />0 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />Please print or type <br />CACoo io79:3 ai <br />1, Generator ID Number <br />--""oll11111111 <br />Generator's Site Address (if different than mailing address) <br />3. Emergency Response Phorne Fopa <br /> g 00 z got 34, <br />02191350'7 JA <br />4. Manliest Tracking NumbPaPrr°' IAIN <br />a"..I kev.c 37.-7 4°Z <br />Tro‘d•••1 CA <br />Transporter 2 Company Name <br />Generators Phone: <br />6. Transporter 1 Company Name <br />1),41,01-- e,Audrynole,vf-a-f ces <br />5 Gentles NAne and MAT& pric,c 5 (\c„. <br />145'0-7 Froni-jec eoi <br />0pkrkli4,ive 6813g <br />US EPA ID Number <br />C4 D3 g , <br />U.S.EPA ID Number <br />Designated Facility Name an Site Address <br />croSby 4s•vei•foi) <br />1433. ur.1144,- 5+ 1.0 1 136-"-c4' <br />Facility's Phone: (./ 9 <br />U.S.EPA ID Number <br />Cfrl- Do 2 gy ef <br />9a. 0b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) .,‘' <br />10. Containers 11. Total <br />Quantity <br />12. Unit <br />WiNot, 13 Waste Cedes No Type <br />ce /V rio Pc R A- e-inze., <br />' .debde-S C(", p 1,e.ce1 m 2. . <br />0 OM tqc,ot, 352 <br />0 <br />‘ <br />, <br />Special Handling Instrucgions and Additional Information cA.5 E. Co p ez pp <br />N <br /> GENERATOR'S/OFFERORS CERTIFICATION: I hereby„declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid 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 lam the Primary <br />Exporter, I certify that the contents of this consignment Iconic:inn to the terms afthe attached EPA Acknowledgment of Consent <br />I certify that the waste minimization statement identified in 49 CFR 262.27(a) (if lam a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatoes/Offeroes Printed/Typed Name Signature Month Day Year <br />International Shipments <br />I- Import to U.S. Export from U.S Port of entry/exit: ...?, Transporter signature (for exports only): Date leaving U.S.: <br />CC 17. Transporter Acknowledgment of Receipt of Materials Ill <br />1- TransporA 1 Pd/Typed Name 1 . 4.144,........------- Signature cc 0 541 k..4v, rvi,f9 T1 w•-m- 0_ I C) <br />Month Day Year, <br />1 S i 13 1 -1 2 Transporter 2 Printed/Typed Name Signature Month Day Year <br />g <br />III <br />18 Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection <br />i <br />Manifest Reference Number: <br />II Full Rejection <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />zi f.73 < u. Facility's Phone: <br />u9 18c. Signature of Alternate Facility (or Generator) <br />Z I <br />1-- <br />Month Day Year <br />I <br />LI Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 3 <br />2. 11 1. <br />Z <br />Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as soled in Item 18a <br />Signature <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />Printed/Typed Name I I I <br />DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />Month Day Year