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Please print or type. _ Form Approved.OMB No.2050-0039 rUNIFORM FIA7ARDOUS 1 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone4.Manifest Tracking Number WASTE MANIFEST `_,4 oo oDAo\ - -1-J i &S - CS-1 1 7Z(,-, 019704373 JJ K S.Generator's 13me and Mailin, ddress Generator's Site Address(if different than malting address) Univ{l '►c,-C,+ b�v l'�(J- +�S r YAl �Gi L Ivo `ct qq �'�Uti Y� P GA L15Z Generator's Phone: V ),nsporter 1 Company Name U.S.EPA IU Number k✓U, ok jun J cyntV '��r0 rv,ce) G�4 D �r?X614 7 Transpler 2 Company Name U.S.EPA ID Number 6 Designated Facility Name and= dress U.S.EPA ID Number tv,u�lny o4 Facilitys Phone: ltaZ�d32- �,� �}i D t/ l� l r 10 Containers 11.Total 12.Unit ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt Not, 0 W z— 3. --I— -- ---—.. - 4. 14.Special Handling Instructions and Additional Information 5 GEN ERATOR'SlOFFEROR'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 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 Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I cerlify Thal 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. Gencrator'slOfferor's P rated' *Name Signature Month Day Year ( d� i -qu- «; don �G-i 7 ZZ 2`' ° J 16.International Shipments ❑Ex ort from U.S. Port of enlrylexit. _ ❑ to U.S. p -- ------ Import --- -- ? Date leaving U.S.: Transporter signature(for exports only): 0C 17.Transporter Acknowledgment of Receipt of Materials Trans r 1 Prinledrryped Name Signal r Month Day Year �G 2Z 2o U Trans rl 2 PrintedrTyped Name Signature / Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space C� Quantity ❑Type ❑Residue ❑Partial Rejection �J Full Rejection Manifest Reference Number: ' U.S.EPA ID Number 18b.Alternate Facility(or Generator) U ii Facility's Phone: Month Day Year w 18c.Signature of Alternate Facility(or Generator) Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1 2. 3. 4. 20.Uesigna Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncted jn Item 18a Year arae P nledl Signatu Month Day --�° EPA Forn1£3700-22 ev.17-17) Previous editions are obsolete. (.-.-,-DE GNATED FACILITY TO EPA's e-MANIFEST SYSTEM