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Please print or type. Farm Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUSre7mtDr IU Number 2.Page 1 of 3.Emergency Response Phone 4.ManfFestTradidng Number <br /> WASFE MANIFEST ± ,� _ JJ K <br /> 5.Gen—ravers Name and Mailing Address Generator s Site Address{if different than mailin address <br /> t'ff#t+t d tT' A Pkt"m(x.103-*'n wars:t; g ) <br /> GeneratQrS Phone: ... <br /> 6-Transporter 7 Comparry,ahe U-S.EPA ID Number <br /> 7,Transporter 2 Company Name U-5,EPA ID Number <br /> .. <br /> 8-Deslgrnated Facility Name and Site Address U.S.EPA ID Number <br /> rr tr}j}North A° n ede.`=i <br /> Facillty's Phone.- <br /> 9a, <br /> hone:9a. 9h•U-S,DOT Description(including Proper Shipping Name,Heard Class,10 Number, 10.Containers 11,Total 12.Un4 <br /> F[M and Packing Group(d any)) No Type Uuantlty 1Nt.NvI. 13.Waste Codes <br /> 1. <br /> lu <br /> 2. <br /> Lu <br /> [a <br /> 3. <br /> 4- <br /> 4.Special Handling Instructions and Additlonal Information <br /> 15. GENERA TOW SIOFFEROWS CERTIFICATION: l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to appticablee international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerMy that the contents of this consignment conform to the Ientts.of the attached EPAAcknawfedgment of Consent. <br /> I certify that the waste minimizat on statement identified in 40 CFR 262.27{a}(if I am a large quantty generator)or{b}(ifI am a small quantity gene�rator)is true. <br /> Genaralor'slQ feror's PrintedlTyped Name Signature Month Day Year <br /> „j 16.international 5hipments n <br /> 0 Import to U.S. ❑Export h.,U.S. Port of entrylexit: <br /> Transporter signature(far exports only): Dale leaving U.S.: <br /> FW 17.TransporterAcknrnvledgment of Receipt of Materials <br /> Transporter 1 Priatedlfyped Name Signature fNonlh Day Year <br /> 4 Transporter 2 PrintedfFyped Name Signatures Month rDay Year <br /> 18.Discrepancy <br /> 18a_Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> F 18b.Alternate Facittty(or Generator) Manifest Reference Number: U-S,EPA ID Number <br /> ,.r <br /> U <br /> LL FacilitysPhone: <br /> t8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> -<9.Hazardous Waste Repor€Management Method Codes(i-e.,codes far hazardous wasts trr'alment,disposal,and racyding systems} <br /> 2' 3' 4- <br /> 20.Designated Facility Owner or Operator:Cartificaflon of receipt of hazardous materials covered by the manliest except as noted in item 18a <br /> P ntedlTyped NameSignature <br /> Monti, Day Year <br /> EPA Form 8700.22(Rev.12-17) Previous edlffons are obsolete, <br />