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PI�a or type Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pag 1 of 3.Em,ergae-�cy Re;pgnse PhoCe, 4.Manifest Tracking Number �� WASTEMANIFES7i�##ai,>, wti' -143-477 5.Generator's Name and Mailing Address ; 0 Generator`s Site Address(if different than mailing address) s l�cra f�t�heit,t~y•k�.iriv CA Generators Phone: - 6.Transporter 1 Company Name U.S.EPA ID Number �YS � Iii 7.Transporier2 Company Name U.S.EPA ID Number SVC 1. J-aeZ511it 8.Designated Facility Name and Site Address CLEAN HARIRE GRASSY mouwrAiN : U.S.EPA ID Number ? C41ESERBF' 7MILES NtRTFK`Ci4,L;E L.-, 41-1 UF F 1- FaciViiys Phone: TLEaLLS A VT 84083 9a. 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 Groff(if any)) No. Type Quantity Wt.Nol. OF (NON, PCB 4� t f t, ur Z 2. w C7 3. 4. n 14.Special Handling instructions and Additional Information `41[ -- .antract retained by gLlneratet- 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 labeledlplacarded,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 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. ge lerator'slOfferors Printed/Typed Name Signature Month Day Year � _ - P ci ) J 16.Intemational Shipments � Q Import to U.S. Ll Expert from U.S. Port of entrylexit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials j2Transporter 1 PdntedlTypedvame Signature r' jam. Month Dan Year Transporter 2 PrintedlTyped Name Signatbre Month Day Year 18.D[screpancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number v u- Facility's Phone: 13 18c.Signature of Alternate Facility(or Generator) Month Day Year Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. [7 4. 20.Designated Faculty Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY