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Please print or type. 1 Form Approved.OMB No.2050.0039 <br /> } UNIFORM HAZARDOUS 1.Generator ID Number, t;" 'J 2.Page lof 3.Emrgg Rg�p ePytli+pg ;4.Manifest Trackin006728322 <br /> g NtT^u'��mber�ht <br /> WASTE MANIFEST { ( 5 G B F <br /> 5.Generators Name and Mailing Address s Generator's Site iff rtt tha iii d ss r <br /> IL'f .- z4 Y l � 7� C s a Lir <br /> J)" <br /> i�) w L'2 ;ilii tri}U9 PD, WIS IBi, <br /> 'Tr-1 P'l'sg� 5.4.= A h�T1b f.u3 � '/i S NrdTR*==;{ T'f1 "rj j�'Gi^i'd <br /> Generators Phone: 7 JJ r.l1 e...�s,: O, ICA 1 21 :a Yts.., To, s,.0 95 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 1ER1's{ (AJ-. .}'T-1 RE-C '�',,I.I C cm..{+ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address OVIFORNFIA (11 TRANKFER, JLC U.S.EDAM Number <br /> Gy"9) 531l "i-Alyn D. H-DG 11 <br /> ca-,e xaa 7 ,r <br /> s n ^,t11TIV ^. r . neat-s e+A T AAA-i nnx,t x <br /> Fal Phone: 6U�l aS'9.2 s'ik.NA,Yi:,,',ivy sd: <br /> gra 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> Na. Type Quantity Wt.Nol. <br /> 1. M14- g CT1+ 1`' .A9D0T S -STE iii;UID .. 1 <br /> RSa. a UL t I TT J ) x <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> /'p yM1m a F <br /> 15. 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 classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a largequantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors Prjp ,/T ed Namg Signs 1 Mo Day Year <br /> 16.Intemafiona Shi s ` _ _ w ea <br /> H Import to U.S. � ❑Export from U.S. Pdrl of entry!exit: <br /> 3 Transporter signature(for exports only): Date leaving U.S.: <br /> of w 17.Transporter Acknowledgment of Receipt of atenals <br /> Trans orter 1 Pr' <br /> p etl/typed Name ` Signature -/7- Man DaY Year <br /> cl- <br /> QTransporter 2.2dQ9WTyped Nam€ ^' Signature �-r^" cold l Day Y. r <br /> Kt- <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑T e <br /> yp El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facility's Phone: <br /> w <br /> I do.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> P- 19.Hazardous Waste Re ori Management Method Codes(i,e„codes for hazardous waste treatmentr disposal,and recycling systems) <br /> / 2. 3. 4. <br /> 20,Designated Facility Owner or Operator:Cedification of receipt ofhazardous materials covered by the manifest except as ndets; Item 18a <br /> PrimedlTyped Name,: ,/ Ji nature fi <br /> 9 4- � Month Day Year <br /> ' -? 1, <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. - ; <br /> GENERATOR'$INITIALCOPY <br />