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+. Pie asdint type. (Form designed for use on elite (12 -pitch) typewriter.) <br />4/(6. <br />Form <br />Approved OMB No 2050-0039 <br />PA Fo 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />E GATED FACILITY;6 ATION STATE (IF REQUIRED) <br />IF M HAZARDOUS 1. Generator IB Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />W [E MANIFEST FSE <br />Ge 'toes Name and Mailing Address Generators Site Address (if different than mailing address) <br />4 <br />Generator's Phone: <br />6. Transporter 1 Company arae U.S. EPA ID Number <br />M diVwONkEWAL W mme"M <br />7. Transporter 2 Compan Name U.S. EPA ID Number <br />�� <br />�e n� o �,► ��. CAoy8ZW3ml 3. <br />8. Dewmaied EacifitxNamat e Address U.S. EPA ID Number <br />CAD0284M0 <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HIM <br />and Packing Group (if any)) �. <br />Quantity <br />wt./Vol. <br />13. Waste Codes <br />No. <br />Type. <br />o <br />' 1c��9sT� Aero S o /s! . �, Vold !9 So <br />2tY <br />CPsicL, No'iekceA0-4rtiy <br />P <br />pool <br />Z <br />c.12<4�z���v�s w•�STp <br />3s <br />S v f co t j t; le e, S C 'j``/ T! <br />f <br />A 14, <br />! S!3 <br />P <br />3. <br />4. <br />14. Special Handling Instructions and Additionartnfonnafion <br />ww okm MM3 Flebmv cbll0 � <br />0 Pko� lam'`` Q '#z Z o <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contenis of this consignment are fully and accurately described above by the proper shipping name, and 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 s PnntedlTyped Name Signature on ay ear <br />p -J <br />5Z <br />16. international Shipments - ----- <br />1:1 Import to U.S. ElEzport from U.S. Port of entrylexit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />E <br />Transporter 1 Printed/Typed Name) % Signature Vont Day Year <br />a <br />0 <br />QTransporte2 <br />ante /Typed Nam Signa ure I <br />Month Day Year <br />b0 v �S� <br />(h �� v �o // 126 IV6 <br />18. Discrepancy <br />18a. Discrepancy Indication Space n� <br />[]rte Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br />1 �� ��� t5 <br />• Manifest Reference Number: <br />18b. Alternate Facili r Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />La <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />S219. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p LLI <br />1 <br />/// <br />2. <br />/V <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the man' except noted in Item 18a <br />Pnnted/T ed Name ure Month Day Year <br />5ig <br />c- AA?, -S <br />PA Fo 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />E GATED FACILITY;6 ATION STATE (IF REQUIRED) <br />