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1 {; <br />Please print or type. (Form designed for use on elite (12rpitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY To GENENAi OR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />C:A.fl�3`M2679 <br />) <br />1--Tai-rzm <br />O 0 2 5 0 5 6 FLE <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />TMCV Lo,�,,s�rtlics DBA 8tookkon +shca LLC <br />4199 GIFid � CL Attn: Maintenance inemgVei <br />sty,, :5206 <br />Generator's Phone: 200 -Z34 -4i'07 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />dmwsad ChamicM Ttrsera;x* hc. (w C;AR0000706Ad <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />AdWrIgillid ChMCW TiteaWkw l <br />6933 Ecfth Bhtd ME NIMLXX22 hZ7 <br />Abuquetrque NM 87107 <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 />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />O <br />Q <br />w <br />LU <br />t <br />i <br />I <br />i <br />14. Special Handling Instructions and Additional Information <br />�.a�Z' Doamerit ii: DST <br />iIERQik AC7863f� Tifii�-� <br />1; 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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational 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) (f I am a large quantity generator) or (b) (if I am a small quantity generat6r) is true. <br />Generalo sl rot's rintedfiyped Nape Signature ', on ay ear <br />j <br />j— <br />16. International Shipments <'--- - <br />❑ Import to U S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature on ay Vear <br />O <br />QTransporter <br />2 Printedflyped Name Signature Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space❑ ❑ ❑ _ <br />Quantity Type Residue Partial Re ctrgtl <br />L <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />-jr,,SEP <br />U <br />08 <br />;+-Q <br />Facilitys Phone: <br />0 <br />18c. Signature of Alternate Facility (or Generator) �* R / W@tilhpi ?—ki� ar <br />Z�r—n.Tr <br />r - .� <br />c, <br />co <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ � <br />1 1 / <br />2. / <br />3. ( <br />4. <br />20, Designated Facility Owner or Operator. Cajtification of receipt of ha jous materials covered by the manifest except as noted in Item 18a <br />PrintedfTyped Name ` Signature /' i Month Dav <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY To GENENAi OR <br />