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Please print or type- Fr)rm Approvpd �}AR Pin 20.-50-0439 I t.hnf rirlr,r Ih NumAnr 2 Psgr 1 of t Fmpra?,rny Rrann,,-filtnnp 4.Manifnsl frarrslnp Mum4Pr �( l]HIFOREMANIFESTS �� i rt r1 1 J JJK WASTE MANIFEST s.. L I L 5,Genpralor•s Name and Ill Address Cpnrrgtnr'x Sir(,Add-r t fir Lilftarnnl Ih=an mailing rxfr1rn981 Generator's Phone:.I I j'7 FI'A ID NI lnrhar ty Transporter 1 Company Name i TranSflr+rter 2 Cnmpan}•NFllnr? III; rim In rigmhr+r 8.peslglt9ldd Fatllgy Nsmo nn,1 Rq:Ail,lrpcc l I!i FI}P If)Numbor ll 1 r,l 'ri li rllf5 I F)r, Facilitys Phone: _: ?' .4 _ Aa. qlb ll S DOT Nscrirhon linolilinp rn prl Shiph+nyl Nnme,Hnrnrd CIngs ID Numher, 10.Cnnlalners_ I f rnlai 12 I if 11 'Nanta bodes HM and Rarki%C-ovp I1f am.fL No typo rallnnlfty 01gn1 1. lit it tF)Irl { f eu L 14.Special Handling Instructions and Additional Information l=rRO!it±- •1 FL 11-77614k,-; 1:�APL�ll I ERS ERG I I4 111; � •_ - , ._ . GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name•and are dasstded,aackaged. marked and Iabeledlplacarded,and are in all respects In proper condition for transport according to applicable internalionaland national governmental regu)aWns if exporl shipment and I am the Pnmary Exporler I certify that the contents of this consignmenl conform to the terms of the attached EPA Acknowledgment of Consent. i oerlii}'that the waste mirfimizaGon statemsnt identified it 44 CFR 262.27(9►(If I am a large quantlly gererelor)or(b)(if I am a sm9B quantity generator)is true. GenratorsrOttera s PnntedfTyp9d Name Signature Mon-0 Jay Year 16.Inlemational Shipments F ❑Import to U S. ❑Export from U.S- Po t of anlrylexit: ? Transporter signalure(for exports only). Dale leaving U.S.: W77 TrampoderAdtnowledgmanl of Receipt of Materials LU Trinspan— Prinled"Ved Ngm f sign J0 Month Day Year CL Z Transporter�P44nnk(rypedNaTe "Slgnah)ref,� 1, Month .it Year 11 , le.Discrepancy 1Ba.Discrepancy Indication Space ❑ Quantity ❑Typp Ll Residue ❑Partial Rejection ❑full RejeClicFl Manifest Reference Number: 18b=Alternate Facility(or Generator} U.S.EPA 10 Number J Facility's Phona: Lu 18c.Signature of Alternate Facility(or Generator] Month Day Year x 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sy819rns) LU 1. 2. 3. 4. 41 Irl _ 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest axraapt as noted in Item Me rinWITyped Name nature Monffi Day Year EPA Form 8700-22(Rev.12.17) Previous edil alobsolele. -DESIGNATED FACILITY TO GENERATOR 1