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Please Print or tyDa. (Form designed for use nn elite 112-nitrhl tvnawhtar 1 <br />EPA Form 8700-22A (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF HtUUIFfl <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />21. Genert I tbeo 0 0 © 7$ 5 8 1 <br />l• A ` <br />22 Page., 23. Manifest TracWng,glumber8 2 6 1 8 J J K <br />U U iS 4 <br />(Continuation Sheet) <br />24. GeneralK6Vt R US <br />25. Transporter Company Name Clean Harbors Environmental Services Inc U.S. EPAIMurabe►ti 0 3 9 3 2 2 2 5 0 <br />26. Transporter Company Name Clean Harbors Environmental Services Inc U.S. EPAIMuft 0 3 9 3 2 2 2 5 0 <br />273. <br />27b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />28. Containers <br />29. Total <br />30. Unit <br />31 Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (I any)) <br />Quantity <br />Wt.Nol. <br />I <br />I <br />I <br />— <br />w <br />Z <br />i <br />w <br />to <br />I <br />t <br />I <br />I <br />i <br />I <br />i <br />i <br />32. special H2rft&2ftnom" al 4RANSPORTATION ONLY for 3rd TRANSPORTER <br />wPnnted(Typed <br />33. Transporter -AcknovAedgmert of Receipt of Materials <br />Name Signature Month Day Year <br />�I <br />o <br />wi '-Z-)�� r� <br />I <br />a <br />0 <br />34. Transporter Acknowled ment of Receipt of Malenals <br />Pnnted(Typed Name Signature Montt Day Year <br />0 c 5 z fi <br />} <br />35. Discrepancy <br />J <br />U <br />Q <br />LL <br />W <br />Q36 <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Z <br />LL, <br />0 <br />EPA Form 8700-22A (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF HtUUIFfl <br />