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'lease pnr*or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST a /y JJ K <br /> 5 Generators Name and Mail ng Address Generator's Site Address(if different than mailing address) <br /> ,*L VA d. I INX:KMdCi MK; <br /> I/40 k Nkl I ITER <br /> xL1.111 'U,t.A 16220 <br /> Generator's Phone: <br /> 6 Transporter 1 Company Name U.S EPA ID Number <br /> .W;i i k W1. INc <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address US EPA ID Number <br /> rLOA^Yt!>1V"SIt IKANSttKt^lalIIY <br /> -,5W US hMt*WAY V9 <br /> Facility's Phone: <br /> ga 9b.US DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt/Vol. <br /> 1. <br /> 0' r. 7 c Ali Az MFN!I" FASxg'R ' ` <br /> p X1N-RC:ItA FM ARIX�I5 V4lA. TF .`i(11.1f) ' <br /> •11 TFRIF&fifPIRIC <br /> Z 2 <br /> W <br /> 3 <br /> 4 <br /> 14,Special Handling Instructions and Additional Information <br /> 11K(*1LE* It13313NKb 1'^Ptk i-111I k1tJ titter 1 T 1 <br /> I-WROENCY CCWACI MIKE <br /> 15. GENERATOR'SIOFFEFOR'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 Pnmary <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)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Pnntedrryped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U S. ❑Export from U S Port of entry/exit. <br /> ? Transporter signature(for exports only). Date leaving U.S.: <br /> W 17.Transporter Acicnowledgri of Receipt of Materials <br /> iTransporter 1 PnntedrTyped Name Signature Month Day Year <br /> a 1s <br /> Z Transposer 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑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 /> uQ Facility's Phone: <br /> W 18c Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> V519 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2_ 3_ 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> PnntedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />