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J <br />Din ter;,+ nr hi !Fnrm rips innari fnr Tisa nn alita 119-nitchl rv-Nwriter l <br />Form Approved. OMB No. 2050-0039 <br />EPA Farm 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 />JJ K <br />WASTE MANIFEST <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 U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />a. Designated Facility Name and Site Address 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 12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity Wt.Nol. <br />1. <br />I <br />0 <br />z <br />w <br />c9 <br />2. <br />EOE <br />---- <br />. <br />3. <br />JUL 2 <br />i <br />4. <br />NVIRO 14 M Et <br />TAL EALT!H <br />DEWAR <br />- <br />14. Special Handling Instructions and Additional Information <br />w u 4 <br />1 a <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 all respects in proper condition for transport according to applicable international 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) (if I am a large quantity generator) or (b) (if 1 am a small quantity generator) is true. <br />Generator'slOfferor's Printed/Typed Name Signature �,' Month Day Year <br />H <br />16. International Shipments <br />El import to U.S. ❑Export from U.S. Part ofentry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />tj <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />Yl <br />QTransporter <br />2 Printed/Typed Name Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection Full Rejection <br />'ICE REFERENCED WASTE WAS RECEIVED, HANDLED AND STORED FOR SUBSEQUENT 0FFSt1E <br />TMENi OR REUSE CROSBY R OVERTON. INC. OPERATES THE PACO.MAMIN%rence Number: <br />18b. Alternate Facittty (o(i3arOtBtddJIED I'0 THEM, BY THE D A -K � U.S. EPA ID Number <br />, ini THE ENVIRONNIFN1'AL PROTELTION AGENCY IN ACCORDANCE WTIN TFIE PROVISIONS OF <br />J <br />(� <br />-nW RESOURCE CONSERVATION AND RECO`/ERY ACT OF 1976 TOGETHER WITH APPLICABLE <br />La <br />tiLTON HAVERPNIC'M WASTE AND ALL THE S WASTE HAS TICNECESSARY <br />Facility's Phone: b-FAERAL AND STATE REGULATIONS, CROSBY a OV <br />W <br />18c. Signa Qj1 r eneratof <br />Month Day Year <br />Q <br />z <br />- <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1 • <br />2. 3. <br />4. <br />ated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />ed Name Signature Month Day Year <br />F <br />EPA Farm 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />