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Please print or type. (Form designed 1w use on erre(12 typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Fon 8700.22 (Rev. 3.1 Previous erns w obsolete. <br />UNIFORM HAZARDOUS 1. General 10 Nufber <br />Z Page t W <br />J. Emergency Response Phoro <br />4. Manifest Tracking Number <br />,.,:. c.,^,-.:�--, ,. <br />WASTE MANIFEST..,., <br />.:.r • " - - <br />ra rR P ^tri ;'. ,�" <br />I 0``.SKS <br />5. Gene9bra Name and Madmg Address C-ematWs Site Address (N different than mai4ng address) <br />f'iCl'1iVf i[[;�t'I:IJ.'� Clf (i•- is Lc',�Yli.%r' 1Jl <br />(,entmmrs Phar: - <br />6. Ierrpater 1 Company Name U.S. EPA ID Number <br />_ _ <br />7. TMspoda] Company Name U.S. FPA ID Number <br />-';" r: .c ^t k'-F.n':i+-'�6`Nich!i-�i_ wC• IR;" irra�7�> <br />6, Desigcated FadNy Name and ads Address u.sEPA IDNemner <br />.. . `_. •�. <br />Faofity's Phone: .-.. .: . .�-..,_ <br />go, <br />9b. US, DDT Desorption, (induding Proper Shippng Name, Hazard Glass, ID Number, <br />10. Containers <br />11, Total12 <br />Uri; <br />HM <br />and Pa <br />Packing Group(dany)) <br />Ouan'iry <br />yY1Nol . <br />17. Wade Codes <br />No. <br />Type <br />z <br />2. <br />I <br />7. <br />I � <br />14.Speua: Handbg lnmuctbnsandAddYaulefonnation <br />- <br />F-R?,f� 1$4 <br />1 7F7'i <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare mai the contents of eus consgnment are fully and accurately, ilesuihed above by me proper shpgrg name, and are classified, packaged, <br />marked aM lalmed'placarded, and are in aL respects in proper wndlion for transport according to applicable inamational and uVonal governmental regulatvns. If erpod sh'rymenland I am Ne Primary <br />Exporter, I certify Nat the conlen's of Vis consignment conform to the term of me afached EPAAC nOwledoment of Consent <br />I certfylhel the waste mnerization slalement identified in 40 CFR 262.27(a) (if l am a large quantity genemtu) c:' (b) tiff am a small puaniry generator) is he. <br />GeneratorslOeemrs PdnWyped Name Signature mals Dry YM <br />J <br />F <br />16. Inierabona Shpmanfs <br />❑Copal to U.S. ❑upon from U.S. Pat of entyfeiit: -' <br />Z <br />Transporter mer s' ore(lorexports oniyl: Dale leaving U.S <br />w <br />17. Transporter Acknowledgment of Receja of Materiels <br />W <br />Transporter l PNnled/fyped Name Sgnature monm Day Year <br />0 <br />if <br />rn <br />Q <br />Transparter2 Printed/Typed Name Signa We Maier Dry Vnr <br />H <br />Discrepancy <br />i1e. <br />/6a. Discrepancy lndcatiar Space [I ❑TYpe ❑Residue E]PartialRejcchon ❑Fail Rejection <br />Manifest Reference Numbs-. <br />16b. Alternate Fadir(or Generator) - U.S. EPA ID N:mrber <br />J <br />V <br />LL <br />Fadfilys Phone: <br />w <br />160. Signalure dAltemale Fadily(or Genemlor) <br />Moran Day Yea, <br />Z <br />N19, <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycing systems) <br />p <br />1. <br />2. <br />21), Designated Fadlty Owner or Operator: Cedgatix of receipt of hazardous maleoals covered by the manifest except as road in Item 1 B <br />PmLd/fyped Name Sgnavre Monti Day Yea' <br />EPA Fon 8700.22 (Rev. 3.1 Previous erns w obsolete. <br />