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Please Ont or type. Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS Gerator Number 2.Page I of 3.Emergency Reapmse Phone 4.manifest Tracking Number <br /> WASTE M ,j <br /> MANIFEST I-i j y j3t q I 026n20 JJK <br /> 6.Generator Name and Mailing Address <br /> I E Address(I different then moiling address) <br /> z"4�A i <br /> Generators <br /> B.Tran$pTrt.71%;par;Name <br /> 3.EPA ID Number <br /> 7.TranspDrTeT 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address- L&EPA 10 Number <br /> A. <br /> I 113-'fff 14V <br /> � <br /> tOM PARCh VA. 91M�13 t�.�k <br /> Fadiirty's Phone: <br /> go. 9b.U.S,DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total' 12.Unit <br /> HIM and Packing Group(If any)) NO, Type Quantity wAm. 13.Waste Codes <br /> UILr f <br /> 3. <br /> 4. <br /> ------------- <br /> 7.—Special Hendling Instructions and Additional I ftlafmalion <br /> 'New <br /> 15. GENERATOKSIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately deso'bed above by the proper ghI&g nem d.ft arclassified,packaged, <br /> marked and labaledioacarded,and are in all respects in proper condition for transport amording to applicable Intemationat and n0onal governmental regulations.If export shipment and I am U Primary <br /> Exporter,I certify that the contents of this consignment owtorm to the term of the attached EPAAckRuMedgmank of Consent. <br /> I certify that the waste m*rIz0on statement identified In 40 CFR 26227(a)(If I am a large quantify generator)or(b)(If f am a small quantity genera"is he. <br /> Generator'slofferor's PrintedTyped Name Signature Month Day Year <br /> At <br /> _j 16.IntemAbo?W Stfipmdnls 1 171 import to U.S. ❑a=xP-ft ft-om U'3- Pont of enLrylexlj: <br /> Transporter signature(for exports only}: <br /> Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> 0 Transporter I PrIntedffyped Name 1 <br /> Signature <br /> Month Day Year <br /> 1 rr <br /> U) <br /> Transporter 2 PrIntadfTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication 5paoe ❑ Quantity ❑Type D R'Id" Ll Partial Rejection ❑Fdl Rljltl <br /> Manffm Reference Number: <br /> 186.Alternate Faclifty(or Generator) U.S.EPA ID Number <br /> LL Facilites Phone: <br /> 18c,Signature of Alternate Facility(or cwerator) Month Day Year <br /> '9,Haz@rqws Waste ROW Management Method Codes{i.e.,codes for hazardous waste treaftent,deposal,and recycling systems] <br /> , I T— — <br /> 2. 3. 4. <br /> 20.Designated FacilltyOwner or Operator:Cerfficallon of receipt of hazardous Materials oovered by the manifest except as Tided In Item 18a <br /> Prinledfry*Name Signature Monih Day Year <br /> 2-G <br /> EPA FDrrn 8700-22(Rev.f2-17FPrevious editions are obsulBle. TRANSPORIER COPY <br />