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-; ease prilt or type. Form Approved. OMB No. 2050-0039 A UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number _ --.. _. • , 2. Page 1 of 3. Emergency Response Phone _ ... .. 4. Manifest Tracking Number 021782281 JJK 5. Generators Name and Mailing Address ... • Generators Site Address (if different than mailing address) - ' '. - • - - ..T.:',.,_:' r". '0 0-, :.: '- : • .. Generator's Phone: ' - • Transporter 1 Company Name U.S. EPA ID Number 7.-3! Services I 2 4 2 4 7 Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address U.S. EPA ID Number 7_ ,,•;.'.i . '.. -1: '_-_-. .1-.; • - ' ----•..7 .. - 61! si_LE. _.. . _ . . .. Facility s Phone: : . - o ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Elm and Packing Group (if any)) Na. Type Quantity Wt./Vol. 13. Waste Codes o 1. g w - , IAJO,OLA) z w 0 4. 14, Special Handling Instructions and Additional Information 1 I.: F:' c.-.:i--11_1-7: # CA5113270, ;:,::: •' .: - 15 GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, marked and labeled/placarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. `r Generators/Offerors Printed/Typed Nape Signature , -i?...1----7 Month Day Year / 4 _ / _., k....-/ 4 C, 0 i'-'t-‘ Vil i . -I 1 I .........,---;,.."-* L3 I-2-4 I2. ...i r_ 16. International Shipments ..---". ,••••.i" Li Import to U.S. Export from 1,1.8:1. •-•-• Port of try/exit: 3 Transporter signature (for exports only): Date leaving U.S.: ce IL t7. Transporter Acknowledgment of Receipt of Materials TRANS PORTI Transporter 1 Printerryped Name r::.t..gi:e . , - _ Month Day Year ,..1..1 f--, )(4-it 13 I .2-1 I Z.1 Transporter 2 PrintediTyped Name Signature Month Day Year I 1 I I DESIGNATED FACILITY 18. Discrepancy Discrepancy Indication Space Li Quantity III Type LIII Residue Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printed Typed Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM