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Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM WARDOUS.1,Generator ID Numhef 2.Page 1 of 3.Emergency Response Phar}a 4.Manifest Tracking Humber <br /> WASTE MANIFEST r' 11/ <br /> 5.Generato's Name and Matting Address - Generator's site Address(it dlfferentthan melting address) <br /> ker) <br /> !x1�7".:�� 114 .i:.yid U:a{� ''�`• .�.rs,�.:.� - - <br /> { <br /> Generator's Phone: <br /> 8.Tfanspoder 1 Company'NaMe U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.5.EPA ii]Number <br /> 8-Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facllo's Phone: ;i'k-•:•;,3 c - Til t1P;�l�'�}- ' {'• ;;'f.1(N'�,ti 3 j u n <br /> Re- 9b,U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 1D.Cordaktars 11.Total 12.Unit <br /> HM and Paddng Group{d any)) No, Type Quantity VVtNoI, 13•Waste Codes <br /> 1. <br /> � �tt�ar r-r��� ��7A�i:.zt,�c �?+�'"!'� ��fir•, �., sti;- [ <br /> 2. <br /> ( <br /> 3. <br /> - t <br /> 4. <br /> E <br /> 3 1 <br /> 14.[Special Handling Instructions and AdManal Information <br /> '3lt?St u .►r:., <br /> • { t f�7l��'lfi1E�'.P L.t:} pT. �'��Jtf�t� <br /> 15. GF_NERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classttied,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations,!f export shipment and I am the Primary <br /> Exporter,I Cari fy that ft contorts of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minknization staWnertt ldanfified in 40 CFR 262.27(a)(it 1 am a large quantity generator)or(b)(til am a small quantity generator}Is true, - <br /> Generalor'slDfferoes PrintediTyped Name Signature <br /> month Day Year <br /> 16,Intemalknal Shipments - <br /> Import to U.S. ❑Export from U. <br /> 11S.f Port of antryle& <br /> Transporter signature.(for exports only): Date leaving U.S.: <br /> 17.Transpwtar Acknowledgment of Receipt of Materials <br /> Uj <br /> Transporter 1 Prntedltyped Namef; a Stgnelura f Month t7ay Year <br /> r � rS e.1.'3-- • , f �t <br /> 2 Transpouter 2 Pr yped Name. - # , <br /> Signature K Moittit Day Year <br /> 2 <br /> 1e.Discrepancy <br /> 18a.Discrepancy Indicalion Space <br /> ❑Ouantiiy ❑Type ❑Residue ❑Partial Rejection ❑Futi Rejection <br /> Manifest Reference Number. <br /> 1$b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Fll'ility's Phone: <br /> In I <br /> Iac.5tgnature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> !9.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycHq systems) <br /> 2{I,D6signated Facility Owner or Operator.CeffiHeafion of receipt of hazardous materials covered by the manifest except as noad in Item 1 ea <br /> Pr ntadfryped Name Signature _ Month Day Yeas <br /> EPA Form 8700-22 JlRev.1 -17) Previous editions are obsolete. TRAN5P TER <br />