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Please print or type. Form-Approved. OMB No. 2050-0039 4 GENERATOR o UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number , 2. Page 1 of 3. Emergency Response Phone ' ; ,' t I 4. Manifest Tracking Number i j: ,,/ '4.: ' ‘''''' ''‘' ''' JJK 5 Generator's Name and Mal g Address Generator's Site Address (if different than mailing address) "? -7 - _:/- • . Generators Phone: I _ I -- Transporter 1 Company Name U.S EPA ID Number is\., , ,-- , l'i. -.,. r • ri... j-i \ . , I Transporter 2 Company Name U.S. PAIDE Number I ' - • Designated Facility Name and Site Address U S. EPA I) Number - , Facility's Phone: ' ga. lib. U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes Eik4 and Packing Group (if any))13. 1/4-.. No Type Quantity Wt.Nol 1. r,: .i • i r.. ^. I ; ,---, , • --.:x-r s *---,/,-- i ii' 4-.. ot-ii`, t '..Cic ..,,. , --.L....440:6La--' 42:1"g7FX6.T.—S--'11.:Arthr 1 ft,\ ,'' ('' f .- .,Ps 2. 3, 4. ' • 14. Special Handling Instructions and Additional Information i'L_ Cr.:, t---.0-A;14:. 4 \ .4" ,u1 . 4 : 4.:.. i.- i'.. . A, ,. . , % i • ' C.:: . C-3.1' il i _ ND7_----,ii 14 0 c • C-_-, - 4 b.71-1 0 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 dassified, 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 26227(a) (if I am a large quantity generator) or (b) (if tam a small quantity generator) is true, Generator's/Offerors Printed/Typed Name ' ' ' Signature Month Day Year I / . I I . _j r-• F. 16. International Shipments U S. Export from U.S. Port of entry/exit: Import to Transporter signature (tor exports only). Date leaving U.S.: CC 17 Transporter Acknowledgment of Receipt of Materials TRANSPORTE Transporter 1 Printedfryped Name Signature • Month Day Year I I.' I I Transporter 2 Printed/Typed Name I Signature Month Day Year . 1 1 . 1 ; I 4--- DESIGNATED FACILITY ---0- ' 18. Discrepancy Discrepancy indication Space El Quantity 111111 Type 11111 Residue Partial Rejection Full Rejection Manifest Reference Number Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I 18c 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 noted in Item 18a PrintedfTyped Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. , 1.