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Please print or type. Form Approved.OMB No.2050-0039 <br /> rUNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ODQUa�t' "JCS 019704373 JJ K <br /> 5.Generator's Dime an Mailinq Address Generator's Site Address(if different than mailing address) <br /> iii b-Gir v t,C)A—L,6 UU U H-Q) (pion <br /> (o��c CZrvcr- , Jr' iCoo iZvNn �d <br /> Generator's Phone: G U 1�y v 'maci Q Gh q5Z 1 <br /> ;—T�ansporler 1 Company Name U.S.EPA ID Number <br /> C/o•� (�q i c�nM�'s� ;c D 05 �� <br /> 7.Transper 2 Company Name ff.. U.S.EPA ID Number <br /> L 04 <br /> 8.Designated Facility Name andSile Q dress U.S.EPA ID Number <br /> !Lt fi 4b'y —v o O'\LU e\l <br /> Facility's Phone: �j Ito 10 , / <br /> ,n <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Not. <br /> 0go <br /> Z <br /> Lu -- --- <br /> 3. <br /> 4. <br /> tM1.Special Handling Instructions and Additional Information <br /> 6 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, <br /> 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 <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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOfferor's P rated ed Name Signature _ Month Day Year <br /> A-6-9. n �'iGi� 7 Z2 2a d <br /> 16.International Shipments ❑ <br /> 11 Import to U.S. Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> fY 17.TransporterAdmowledgment of Receipt of Materials <br /> w— Month Day Year <br /> iY Trans r 1 Printed/Typed Name Signal <br /> Cl Signature Month Day Year <br /> z Trans rt2 Printed/Typed Name^ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> t— <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> Z <br /> U2 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. <br /> LU t 2. 4. <br /> 0 <br /> 20. esignatedFacifily Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted n Item 18a <br /> Pnnled/T me Signal u Month Day Year <br /> EPA Form 8700-22 ev.1 -17) Previous editions are obsolete. DE GNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />