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r <br /> Please print or type. Form Approved.OMB No,2050-0039 1 <br /> UNIFORM HAZARDOUS 1.Gene for ID Number 2.Pap I of 3.Emergency Response Phofte Manifest Tracking Number <br /> WASTE MANIFEST e'A C/ o 2—Z,-1 1 <br /> 1 1116-563--7170 019-1-328804 JJK <br /> 5.Generators Name and Mailing Address kq Generators Site Address(if different than mailing. dd <br /> re" <br /> /0 "I h; 1 ,,, k�Ala JA*1 4 e,�_ <br /> 44 9 21.q q0-1� <br /> V-41 <br /> Generator's Phone:L"1-474—"1c/QQ Mtw <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7( xtc T nsporter 2 Ccrnpaqy�N I.S.EP be)(Q10TIs Tnn CDah <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phon&/4") <br /> -ga. 9b.U.S.DOT Description(Including Proper ShIpping Name,Hazard Class,ID Number, 10.Conlaineis 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtf*]. <br /> 0 0,i? <br /> 2. <br /> LU )0 <br /> 3. <br /> 4, <br /> 14.SpecialHandling Instructions and Add'Uona;Information -7 T/W <br /> 716 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and laboledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and lamthe Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I carlity that the waste minimization statement Identifed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoesiOlffefor's V C)Prinleti?fyped Name Signalye, Month Day Year u 4k,t ti e�'VA <br /> _1 16,International S EJ Import to U'S. ❑Export from U.S. of entry/e.,it: <br /> i-- IV <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> K 17,Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Transporter I Prinled/Typed Name Sgnalup/ Month Day Year <br /> Z Tr nspoAer 2 Printed/Typed Nam gnpiur Mth <br /> bau x <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quality Type ❑Residue P.dw Rejection ❑F—]Fufl Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J II <br /> Facilltys Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codas for hazardous waste(Teatmonl,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintediTypad Nam Signature Month Day Year <br /> —4. 1 h'�1101 121 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. L DESIGNATED FACILITY70 GENERATOR <br />