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If <br />into • rtype (Form <br />`. EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. <br />i <br />I : <br />DESIGNATED FACILITY TO GENERATOR <br />oeslgnea <br />ror use on surei,'iz-pncn) [pew ReG): •. : ronn oven uvea 14u." <br />UNIFORM HAZARDOUS <br />1.0ID Number : ''' <br />2 Pagb 1 <br />3. Emergency Response Phone <br />4. ManitesfTracking Numpb�er f CF <br />WASTE MANIFEST <br />��a9P3»ri!'77 . <br />r�►-�'Ir1^ai' Y <br />d wJ "4 f FLC <br />5: een�ne¢¢ratofs Name Address Gener a, its Address (if different than mailing address) <br />�(and <br />LLMailing <br />tyy�f (�+ � 1 y( <br />Y iI V.!1,� i., t il,l'Y4W W�'Vyni J' 1.kJW�Yj��f�{i'!a7 y �/eLj4o[A� iA- LLC <br />, I.A&Wtio wYIVe:%�S' <br />lL`�q�y'o,�, <br />•�y�4���,3((���firfr�°��f��GO4/Ap1, {{�}W��,�L�y1��y�{6�*tAi <br />4Ti7�.�Ya4 vy CA $A`.MreA.T,t - <br />Generator's Pkhe: 269MJ V <br />Transporter 1 Gogany Narne U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8, Designated FaciOty Name and Site Address U'S. EPA ID Number a <br />Faculty's Phone: 'en)AS4- '• ' <br />ga <br />9b. U.S, DOT Description (Including Proper Shipping Name, Hazard Uses, ID Number, <br />10. Contaners <br />II.,Total <br />12. Unit. <br />13, Waste Codes <br />No. <br />Type .. <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />1 tt �AC�i1Pc&'tt ii,'3flE'3 <br />Z <br />v �wt ST6 i7d3 5rg ds' i� AIS. �,c'10ueraixl yd�Sti.Pialldia)v a, _N's, <br />l <br />~ <br />:G✓ <br />�� <br />331 <br />3IM1701 VIN4WIL"5id4. 1., <br />O,iA <br />4. <br />14, gipeclaiHendling Instructons and Additional Information <br />JJ 211 :. c <br />IF GENERATOWSIOFFEROR'S CERTIFICATION: I hereby'declar that the contents of this codsignment are fully -arid accurately described above by the proper shipping name, :and are classified, packaged, <br />marked and Ia0ledfplacarded, and are in all respects I� proper condition for•transport according to applicable intemational and national governmental regulations: If export shipment and I am the Primary <br />Exporter; t certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I cerufythat the waste minimization statement Identified In 40 CFR 26227(a) v i am a large quantity generator) or (b) (if I am a small quantity generator) is try& <br />aneratarsl rots Printed/Typed n a ,; on ay Year . <br />�r <br />/4 ...e ..0., <br />TO <br />-1 <br />Z <br />16: Int naticrral Shipments Export from U.S.. Port of en !exit <br />❑ Import to U.S. trY <br />Transporter signature for ex onl : Date U.S.: <br />17. Transporter Acknowledgment of Receipt 4 Materials <br />Transporter 1 Printed! Name Signature Monthay Year <br />ype <br />C- . �': <br />a <br />fanspo r 2 Rnted/TypedName Signatur,e Month Day Year <br />18. DRrepency <br />18a. Discrepancy Indication Space ''❑ Quantity ❑ Type ❑ Residue ❑ Padisl Re}acti�on ❑ Full Rejection <br />Manifest Reference Number.: <br />J <br />18b. Altsmate Facility (or Generator). U.S. EPA ID IN 0 Q n 1 <br />_ <br />_ O l' <br />Facility's Phone:- <br />loc. Signature of AlternateFacility(orGenerator),' . y Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />IALI <br />20. De 'gnated^Facility 0 ner or Operator. Certification of receipt t azardous materials covered by the manffest excepfas'noted in Item 18a <br />Printedifyped Name t :. Signature M th Day Year <br />. <br />Vrx4.. �. ' %b r fir. <br />`. EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. <br />i <br />I : <br />DESIGNATED FACILITY TO GENERATOR <br />