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Please orint or bee. (Form destoned for use on elite (12 -pitch) Npsiter.) <br />Form Aooroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />: `AZARDOUS <br />1 Generator ID Number - <br />2. Page 1 of- <br />3. Emergency Response Phone <br />4. an at Tracking Number <br />Ute-; <br />WASTE MANIFEST <br />r .."A i P 'S 0 w w -M 9 :;s'-� <br />:�. <br />;i`a�Ti�i'� ��� �:� <br />C C <br />tj � �. � � v aJ � 7 F L E <br />5. Geneal Name and Mailing Address Generators Site Address (if different than mailing address) <br />re. i� <br />� .-�at1:��:1 v yt-a l��-:. :_5 4'i:Rr wl4 ';iizc. <br />Generators Phone <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />+b ..;-i'%s=ar ';€�Fe^,hSEt'CA3"v iA A.iy' Safe ._" 2 2 <br />7. Transporter Company Name U.S. EPA ID Number <br />I <br />8. Designated Facility Nami Site Address U.S. EPA ID Number - <br />,.,3 s� Awbtoy-, A�---it p:;>d� i.s.5.: e ,c r. yy. 5 al : , r�, -• <br />;s <br />.s <br />Facility's Phone: ' <br />ge <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 />WLNoI. <br />w <br />w <br />22*.i?.. 'aa_ <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: 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 labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations, If exportshipmentand 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) if I am a large quantity generator) or (b) (d I am a small quantity generator) is true. <br />Generator's/Offerors Pnnted7Typed Name oignature Month Day Year <br />t <br />ri <br />r <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: <br />Transporter signature for ex rts onl : - Date leavingU.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedlTyped Name Signatures Month Day Year <br />4year <br />z <br />Q <br />Transporter Primed/Typed Name .Signature Month <br />tY <br />I <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantity 11 Type ❑ Residuelection ❑ Full Re <br />ElPaNal Re jection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) - - U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />z <br />+ <br />y19. <br />Hazardous Waste Report Management Method Codes ife., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. <br />4, <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest excep: as noted in Item 1 Be <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />