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Please print or t,Gener Ion ID Number Form Approved.0M9 No.ZWO39 UN►FORM HAZARb0U5 2 Page 1 cf 3.Emergency Response Phone��f7jngjjumlberk WASTE MANIFE57 �(%v0 l—� r77rr J K 9 6 6 � r:��is 5,Generator's Name and Melling Address T -0 Generator's Site AM Mss lit different than mal in as f�'z � Generator's Phone: �� X' r7� , `'''/CA � 1 6.Transporter 1Com any Nama U.S.EPA ID Number 7. nspoder 2 Compomo U.S,EPA ID be iino lft�) Spoattl WAM 661"Is B.OasignatedFOGWyName and SiteAddcess ', G3F'pDl/ U.S.FPA ID Number Fadlitys Ba. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conialners it.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes r No. Typa Quantity WINCL wbrocf 0/00 LU ---- 3. 4. 14.Special Handling Instructions and Additional Information ] •; �1D •z f y�� 7_D ,s.S�w.�- 15. GENERATOR'SIGFF£ROR'S CERTIFICATION:I hereby declare that the contents of[his consignment are filly and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are In all respects in proper conchion for transport according to applicable international and national govern menial regufallons.1lexporl shipment and I am the Primary Exporter,I certify that the contents of this consignmentconlorm to die terms of the attached EPAAcknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I em a large quantify generator)or(b)(f I am a small quantity generalor)Is true. GeneratoNofferor's Pdnledjyped Nam_ sungMonth Day Year G � �� N �- 16.International ShItaftlits ❑Mpal to US. ❑Export from U.S. rt of entrylexil: _ Transporter signature(for exports only): Date leaving U.S.: 17.TransporterAcknrnAedgmenl of Receipt of Materials Transporter 1 Printe ped Name Signalu , Month ay Year ited rL T ergPnnted/TypedName Sign Ea IMonth � pyv I_y (MI'L L-2� 18.Discrepancy 18a.Discrepancy Indication Space 1:1 Q.Uty ❑Type ❑Residue, ❑Partial Rejection ❑Full Rejecliat Attnifesl Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number a U uQ Fad01Ys Phone: i LO 18c.Signature of Alternate Facility(or Generator) Month Day Year 19,Hazardous Waste Report Management Mathad Codes p.e.,codes for hazardous[taste beatmenl,disposal,and recycli systems) W `,aa;•• :Kr ori ,k:: 20.Designated Fadllly Okmeror Operator.Certification of receipt of hazardous materials covered by thio manNoslexoapt as Well in Item 18a ` '��;'"'�''" +•; Prnled(TypedName �Signature •rt , ' I EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. DESIGNATED F Y :r.si 'i,�•�i`.♦'CL'�Ti`�^�Hik<�� e tt !. Y�;