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Oct 17 11 10:47a Microsoft <br />PleaSe mint or tvnp fFnrm H.--,ionpd fnr use on elite f 12-oitrhl tpewriter.) <br />916-685-1902 P.19 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22A (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />21. Generator ID Number <br />22. Page1'.,-,,-.'. <br />23, Manifest Tracking Number <br />(Continuation Sheet) <br />J' <br />24. Generators Name. <br />'A <br />U.S. EPA ID Number <br />25, Transporter Company Name <br />A -'r <br />U.S. EPA. ID Number <br />26. Transporter —.— Company Name <br />27a. <br />27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />28. Containers <br />29. Total <br />30, Unit <br />31. Waste Codes <br />No. <br />Type <br />HIM, <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol. <br />LU— <br />- <br />— <br />-------- <br />LU <br />II <br />-J. <br />32. Special Handling Instructions and Additional Information <br />33. Transporter —Acknowledgment of Receipt of Materials Month Day Year <br />uj <br />PrintediTyped Name Signature <br />0 <br />34. Transporter —Acknowledgment of Receipt of Materials <br />Signature Month Day Year <br />Printed[Typed Name <br />I J <br />35. Discrepancy <br />LU <br />t;z <br />36. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />EPA Form 8700-22A (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />