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Please print or type. Form Approved.OMB No.2050-0039 V5—Generators RM HAZARDOUS 1,Generator€D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST �.7 +� JJ K r Name and Malting Address 3 Generators S€teAddress(ff different than mailing address) Generator's Phone: . 6-Transporter 1 Company Name U.S.EPA 0 Number 7-Transporter 2 Company Name U.S.EPA 10 Number �4:... S.Designated Facility Name and Site Address U-S,EPA iia Number Fmflil e5 Phone: t - ga, 9b.U.S.DDT Description(including Proper shipping Name,Hazard Class,10 Number, 10.Containers 11 Total 12,Unit HM and Packing Group(if any)) No, Type Quantity Wap] 13.Waste Codes 1. LU i t.rA rl4.3dir:i's,= rgr.: r r-, .w z 2- .i' pL_ •t �: i1:.3 e,IL 3 4. .14.Speolal Handling Instructions and Additional Information 16, GENE RATOR'SlOFFEROR'5 CERTIRCATfON: I hereby declare that the contents of this consignment are fury and acasrately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition far transport according to applicable intemationaland national govemmental regulations.if export shipment and I am the Primary ExWer,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowie gment of ConsenL 1 certify that the waste minimizatlon statement identified In 40 CFR 26127(a)(91 am a large quantitygeneratoo or(b)(if i am a small quantity generator)is hue, GeneraterstOfferorsPrintedlrypedName Slgnature �- y Month Day Year -j 15,International Shipments •+-- ❑Import to U.S. L1 Export from U.S. Port of entry/exit Transporter signature(for exports only): pate leaving U-5,: W 17.Transporter Acknowledgment of Receipt of Materlals Transporter 1 Prfnte yped Name )r i Signature O ; t a Wrrih Day Year CL z Transporter 2 Pdntedffyped Now J Signature A • Month Day Year 1S-Discrepancy 18o-Discrepancy Indication Space Quantity ❑Type ❑Res6due Partial Rejection ❑Full Rejection Man]fest Reference Number- 18h.Alternate Facility(or Generator] U.S.EPA ID Number U LL. Fadlity's Phone: 1Qu 18c.Signature of Anemone Facility(or Generator) Month Day Year 39.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatmenl,disposal,and recycling systems) t r 7= { 2• rill 3. 4, 'r 20.Designated Facility Omer or Operator.Certification of mcelpt of hazardous materials covered by the manifest except as pried in item 1 a Prrttedfrypsditante J Siguaha�J '" mo {& pay Yaar EPA Form 8700-2Z Rev.12217) Previous editions are obsolete. r .� TRANSPORTER ®p