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Please print or type. Folin Approved.DMB No.21150-0039 <br /> UNIFORM 14AZARDOUS 1 G vterator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest TrraNumber <br /> WASTE MANIFESTf r r .•... .;i f! 22913557 J JV <br /> 5.Generators Mame and Mailing Addre,�s _ 3 Generator's Site Address(f€different Ihan mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name ; <br /> U.S.EPAID Number <br /> 8.Designated Facility Name and Site Address L.S.EPA IR Number <br /> 's �'N�lsxtf3n�4f t'klfy(}►f <br /> ^•r..,'EENT tiriJfYi�{?i? �:ri :'�}1�L-�f:1`,��try� <br /> Facility's Phone: <br /> ga• 9b.U.5.DOT Descripfion(including i�roper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 92.Unit <br /> HM and Packing Group(If any)) 13-Waste Codes <br /> 1 No-. Type Quan* Wt./Vol- <br /> ww- 4 <br /> x 2. <br /> W <br /> C.7 <br /> 3- <br /> 4, <br /> Stf <br /> a <br /> 4:Special Handling Instructions and Additional Informal1w <br /> 15, <br /> GEN ERATQR'S;DFFEROR'S CERTIFICATIGN:I 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 appllcabte intematonal and national governmental regulations-If export shipment and I am the Primary <br /> Exporter,I certify that the earyrents of This emsignment conform to the terms of the attached EPAAclmoWedgment of Consent. <br /> I certlfy that the waste minlmizatlon statement identified in 40 CFR 262,27(a)(if i am a large quantity generator)or(b)(•rfl am a small quantity generator)is true- <br /> Geresrat[ 4*$arces Printed/Typed Name Signa Month Day Year <br /> s <br /> 19.fnternet anal Shipments $ <br /> ❑Import to V.S. ❑Export from U-S- Port at enrryla>at: <br /> Transporter,signature(for exports only): Date leaving U.5.: <br /> a 17.TransporterkknowledgrnW of R 1pl of Materials <br /> cc Transpoierl'PrintedffypadName 3 ' # Signature ; ^. Mordh Day Year <br /> CLt <br /> = Transporter 2 Printedfryped Name Signature, A Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 180,Discrepancy indication Space <br /> ❑ 4uant[ty ❑Type ❑Recldue Ll Perm Rejection ❑Futl Rejeefim <br /> Mantled Reference Number, <br /> 186.Alternate Facility{or Generator} U.S.EPA]D AEum6er <br /> CJ <br /> Facility's Phone: <br /> W 1&-Signature of Aitemate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> r 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Cerfificat on of receipt of hazardous materials covered by the manifest except as'nded in item 1 B A <br /> Printart!{yped Name= wgaure . <br /> l j _ r fUr Day f Yeah <br /> EPA Farm 8700-22(Rev.Q-17) Previous editions are obsolete. <br /> TRANSPORTER COPY <br />