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Export Irom US Port of entrytexit
<br />Date leaving U S
<br />DResdue D Type Partial Retectice El Full Repctor, 18a Discrepancy Ind,cation Space Ouanlity
<br />US EPA ID Number 18b Alterrale Facility (or Generator)
<br />PnntectiTyped Name
<br />20 Desigr ated Facility Owner or Operator Certification of acelpt of hazardous materials covered by the manifest except as noted m Item lea
<br />Signature MrtnIn Day Year
<br />1 1 1
<br />EPA Form 8703-22 'Rev. 3-05) Previous editions are obsolete
<br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRIII
<br />V-- Photos from Brandon Espinoza, received 2/28/2023 Priam firm BrUnc191 cpricj reCeweci 16 I nabona' SInprnents
<br />Import to S
<br />Transporter signature (for exports only)
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<br />Month Day Year 8c Signature o' Alternate Facility (or Generator)
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<br />0 c-n- 19 Hazardous waste Report Management Method Codes e. codes for naiardous waste Peatment. disposal, and recycling systems)
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<br />14 Ssx..al Handlog Instructrons and Additional Information
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<br />15 GENERATOR:Sip FF ER OR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acarately described above by the proper shooing name, and are classified. packaged.
<br />marked and labetedipacarded and are in all respects in proper =Orton for transport escort:1)N to applicable internabonal and national governmental relations If export shrpment and I arn me Pnmary
<br />Exporter. 1 ceittly that the contents of thcs consignment conform to the terms of the attached EPA Acknowledgment of Consent
<br />I celify thit the waste rnwumaabon statement tdenlied in 40 CFR 262_27(a) (if I arn a large guanllty generator) or (b) (if I am ty generator) is bye
<br />Generatcrts/Off,ro(s Pnril•diTyped Name
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<br />Mond, Day ea
<br /> 00 94 ID—.
<br />Signature
<br />MocAh 'Day Year
<br />I ‘0
<br />Month Day
<br />1
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<br />1O
<br />18 0 screpancy
<br />Manifest Reference Number
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<br />17 Transporter Acknow4edgmeol of Recerpi of Materials LLI
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<br />X Tr lc, 2 PrinteeTyped Name
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