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1 <br />Plane poor or tae. fFarm designed forum on elite (12-oitchl Nnewnter.l Form Approved. OMB No. 2050-0039 <br />EPA 8700-22(Rev.3-05) Previous editions are obsolete. 57BAP ' /j - �' - DE§IGN6TEDFACILITYTOGENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. M(aann�hdTnc�ldng Nw/hh�er '- <br />9 FLE <br />WASTE MANIFEST <br />i'UTli1;7p,,,;5ni <br />i <br />c;^,n 4:1 -9' -'?0 <br />VO0 17+4T <br />5. Generators Name and Mailing Address Genenlds Site Address to dieerent than maing address) <br />� Lx r ri F'R''er <",7'� IF` RWILON 1d`ITER 4.TaBS•T1Z !&a SHELL Oil, PVf.O'{_'T: D'S ` ". <br />F. '�. BOX 264:,1 iIVTK: 9. <br />H•AJSTUt7, _ 7?252-28gB 38,9 NAyY Vb.1Y' <br />Generators Phone: ^t ': S'1`4+ -h :'r'fi , <br />6. ransporter 1 Campa; Name U.S. EPA 10 Naber H <br />...Bi,"1'p,'I11'tit 'T RUC}".I }2L• r I6 a, 4 f-Rnn-T moi;. 41^•9 <br />7. Truesporer 2 Com Name ff �' .-U.S. EPA 10 Number <br />f - y/ / . ((L/ c'AOy"b24Z/41Ylb <br />8. Designated Facility Name and Site Address - U.S. EPA 10 Number <br />:'Ri09'i fiND fx7HR.7'oN, IHi'.. <br />lti3C W. 11'P:ti 5`"P5L'1' j - <br />LONL h'J .r. Cy dI <br />C'.AD0284C190i) <br />Facility's Phone 5152 n_. =445 <br />9a. <br />. 9h. U.S. DOT Description (includng Proper Shipong Name, Hazard Clash; ID Number, <br />10, Contanere <br />11, Tara <br />12. Unit <br />13, Waste Codes <br />Na. <br />Type <br />HM <br />and Parking Group(d any)) <br />OuartiN <br />Wim. <br />K <br />O <br />1. <br />SZI ' f s i..•S C+SIT?IHcIJ FLA:41M.B L <br />5L� <br />a <br />X <br />- LUF Nd aND <br />1 yU1L N .:� 3 Cfi H'O <br />I <br />['F1 <br />Sii <br />01199i, r.; ii e:•.�.�#i_e <br />e"1 <br />z <br />2. <br />w <br />C7 <br />3. <br />4. <br />4. <br />14, Special Handling InvWNOra and Addltlonal Information <br />21 H�;U1t Ei+,EP _42t•"i FHeWi'e NtRiE'-eR (600; <br />cc.CE ILg, W?J2`T.FR: 42339 F0�. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hely and accurately deunbed above b/ th Paper adppkg name, abe are classified • Pte• <br />marked and Iabelediplaa;ded, and are n a8 respects In pnper condition for transport according to appM261e international and nal governmental regulaeans. If export shipment and I am the Primary <br />Exporter, I center that the contents at this consignment conform to the terra at She attached EPAAdmWedgnwnt of Cement <br />I cerely Nat the waste minimiadon statement idensfM in 40 CFR 262.27(a) jd I am a large Quangly generator) or (b) (N I am a small q;antily gmwanr) te hue. <br />CkmerwoesVeroes PnnjTTyP@ Namef S aturte -morm ay ear <br />-a <br />16. International Shipments ❑ Import to U.S. ❑ Exportfran U.S. Port of antrylexM <br />Tran iter signature for export oral ; Dae learn U.S.: <br />w <br />17. TnnsponerAdtmMedgment of Receipt of Wachs <br />Day <br />Tons 1 PMtedlTyped Name nor / 11.4 <br />Ife <br />nalma Month Day Tear <br />Tra%Vorlw 2 PmfeNf a/ne nV <br />j /l� U V(7 D; <br />Jf lJ? G3. <br />04 U U <br />1e. (Discrepancy <br />18x Disse IMlcotion Spacen ❑ P ❑ Full Rejection.1 %a rile 12Gi 4 CA. 6{.,.; �1y4 YO�T t�I^COL I. N hater rMrA F, <br />Mahesh Reference Number. <br />I& Planate Facility (a Genentar) U.S. EPA 0 Number <br />J <br />' <br />LL <br />Facclitys Phone: <br />w <br />18c. Signature ofAltemate, Fadity(or Gement&) Month Oay Year <br />tR <br />Z <br />s2 <br />19. Hazaydaus Waste Report Management Method Codes rte., codes for hazardous waste treatment. disposal, and Mgdng systems) <br />G <br />1. <br />Q/ <br />2. - 3. <br />4. <br />20. Designated Fatality Owner or Operator Cere8abon d receipt of hazardous materials covered by the mamlest eggept as now in Mem tea <br />PnntedRyped Name ^,Stgswoo, Month 0ay Year <br />EPA 8700-22(Rev.3-05) Previous editions are obsolete. 57BAP ' /j - �' - DE§IGN6TEDFACILITYTOGENERATOR <br />