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Please print or tvoe. (Form desioned for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3 Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST' <br />JJ <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <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 />WtNol. <br />1 <br />� i <br />Zul <br />2. <br />CEIVE-E <br />3. <br />K E ,: +P�Rr,i �,f , tet., ,1 <br />� , � • a � 1)t r:ii r .;� , ,.. _ua� roc ::I xc.tw ,.� < r ;; <br />� <br />_ ,(� ..__...._ <br />�U� <br />� <br />� •, � „ ,as <br />f h._ nkU1T:C±VN 3GENCY IN AUCORDANCE WM4 ,HF' M0 I.. <br />_ '� 'r <br />••, •..'. nb v 7b l' GEn1VR '>r'1rt. ,�.:' � . <br />i <br />4• t -r ' P,EGiil.' not•tS. 1=,c, & OvL'tTON HAS Atl Or Tt$ 'IF0 ;NF1•': <br />: • ' <br />tiG1Z7t�blC:•".J WAS18 ANI) AI_A. 7'i� 4/AS'fE HAS B!•3+1I }1r'+i`m)L' <br />? <br />ENVIRONMENTALt <br />SALT <br />1'Y::tlslfrS ail .a;:^>.' 7x18 <br />° ry.10R "IT"`Y <br />D <br />PAR MEN <br />14. Special Handling Instructions and Additional Information <br />;. <br />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, <br />marked and labeled/placarded, and are in ail respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment <br />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) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatots/Offeroes Printe{d✓lTy)pjedy Namee� Signature .-A �? i <br />Month Day Year <br />}`.� t "+:'t 1 W� I <br />�J �7 <br />!f 1. % 9".*•.� <br />-j <br />I.❑ <br />116. International Shipments <br />Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />CC <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrinledfTyped Name Signature <br />Month Day Year <br />Z <br />Transporter 2 Printed/Typed Name 'Signature ' <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J_ <br />V <br />I <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C3 <br />1. a + <br />2. <br />3. <br />4. <br />9 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name , Signature <br />F <br />MonthDay Year <br />, f <br />I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />