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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Fnnm Annmvuri nmp Nn )nrn_nn4a EPA Form 6700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone m�beeWASTEMANIFEST Track' Nu2842 �r,1 ! _ Y ✓']-44. EMaaniiffe�st lJ U L O 4 2 JJ K 5. Gnerator's Name and Mailing Address _e � Generator's Site Address (d different Than marling address) _ u`„ --L..:571( b Sew 6� 7 Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: `5� z- ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt./voi. n -- -_- w Uj 3. 4. 14. Special Handling Instructions and Additional Information 15 GENERATOR'SIOFFEROR'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 labelediplacarded, 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 EPAAcknowledgmeni of Consent - I certify that the waste minimization statement identified in 40 CFR 262.27(a) (rf I am a large quantity generator) or (b) (if I am a small quantity generator) is true. re—ralor'sJOfferor's PrintedrTyped Name Signature Month Day Year -j 1-- 16. Intemational Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit Transporter signature (for exports only): Date leaving U.S.: a w 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a z Q Transporter 2 Printed/Typed Name Signature Month Day Year H 18, Discrepancy 18a. Discrepancy Indication Space ❑ Quantity Type ❑Residue ❑Partial ReectioFull Rejection Manifest Reference Number. = , 18b. Altemate Facility (or Generator) U.S. EPA ID Nulnbef J ra+” Facility's Phone: SEP 0 8 w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) J r- ;,r r " k n n „— n ,T 1 1 2. 3. 4. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Ll20. Pnnted(Typed Name Signature Month Day Year EPA Form 6700-22 (Rev. 3-05) Previous editions are obsolete.