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F Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 111.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number I WASTE MANIFEST 4029Q256 F`E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) l . , 2 H. Generator's Phone: s _ umbe 6.Transporter 1 Company Name .S.EPA ID r 7.Transporter 2 Company Name r^ P U.S.EPA ID Number 8.Designated Facility Name and Site Address. U.S.EPA ID Number Facility's Phone;' ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. O s _ LU Z 2. W 3. 4. 14.Special Handling Instructions and Additional Information - 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internati d 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 EPAAcknowledgment Consent, I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) (b)(if I am a small quantity ge is true. G net or ors Printed/Type d NameS'g ure,- �, onth Day Year C 4 04 IVA vlon 1 _J 16 nternational Shipments El Import to U.S. ExpoU.S. Port of en /e ? ranrt f m sporter signature(for exports only): Date le 16 S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PrintedlTyped Name Sign ure Month Day Year QTransporter 2 PrintedlTyped Name � /e� � Signature Month Day Year 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V tai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1' 2. 3• 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name 4/M', R LU-07,TSignature A _ Month Da Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EF A's e-MANIFES^GT SYS,R(T;'(E.J,M <e7r00 7 ' S ! ..,, �. , U