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P�I)r type. Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Pa e 1 of 3.Emergency Response Phone 4�Iar�fe Trackhj}o Number,; UNIFORM HAZARDOUS 9 ffll�all�`''vv11 �� � . WASTE MANIFEST' j S it 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - - - 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. -- Z 2. I I w 3. 4. I i I 14.Special Handling Instructions and Additional Information l:F1 a r,-t' C . ,. .' .:":� :. ';:_ .: ;: c'....,,: .;. .:'1 �'IC� .:)"•nii�_ij:j Y'1.f7�`C7 i�i, J ... 15. GENERA70R'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 international and national govemmental 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 arq a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature l Month Day Year _j 16.International Shipments r` ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials OTransporter1 Printed/Typed Name Signature a! y 1 ) Month Day Year Cn z Transporter 2 Pri tbd/Typed Name � J'' Signature !J Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection � 181b Manifest Reference Number:.Alternate Facility(or Generator) U.S.EPA ID Number. U LL Facility's Phone: w 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q z w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 0 \ 2. 3. A. 20.Designated Facility Owner or.Operator;Ce(tifcation of receipt of hazardous materials covered by the manifest exce4 ash oted in Item 18a Printed yped Name 1 Signature Mon?tr Dqy Year EPA Form 87-00-22(Rev.12-17) Prevf6us editions are obsolete. j CP:t.tC ni t..ECi FAC'li i i?'r0 GENERATOR t