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Please tint or type (Form designed for use on elite (12 -pitch) typewriter.) <br />Fours Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 305) Previous editions as obsolete. <br />DESIGNATED FACRITY S CO <br />p 9 <br />1. Generator ID Number <br />2.Pagetof <br />3. Emergency Response Phone <br />4MandestTrocking Number <br />UNIFORM HAZARDOUS <br />JJ•� <br />WASTE MANIFEST --- <br />-t�[ <br />5. Generators Name and Marling Address Generators Site Address (d different than ma3ng address) <br />Generalors Phone: <br />6. Transporter i Company Name U.S. EPAID Number <br />7. Trbnsporter2 Company Name U.S. EPA ID Number <br />6. Designated Fars Name and Site Address U.S. EPA ID Number <br />Fauldys Phone: -' <br />9a. 9b. U.S. DOT Dasaipbon (ndudrg Pmpe'Shippmg Name, Hazard Class, ID Number, 10. Containers m -now 12 Unit 13. Waste Codes <br />HM and Packing Caaup(dany)) No. 1YDe OuanBN WWOL <br />aO <br />K <br />i'• r <br />z <br />2. <br />W <br />r.7 <br />3. <br />4. <br />14, Special Handling Instructions and Additional thlonnal n <br />15. GENERATOR'SfOFFEROR'SCERTIDCATtON: I hereby mclare that the contents of this consignment are fully and a=mt* described above by the propershippin9 reme, and we classified, Packaged, <br />maxed and Iabe"placarded, and are in all respects in proper condition for hansport assuming to appfeable international and national gownrmenlal regulations, bexpon shipmem and I am the Pdmmy <br />Exporter, I certiN Etat the contents of Nis consignmentonNorm N the tams of the attached EPAAcWavkdgmenl of Consent <br />I certily that the vaste minim¢ation statement identified in 40 CFR 26227(a) (f I am a large quantity Lor (b) (dl am a small quantity generator) is We. <br />Gerarolorsl0ffwwS PdntedfTyped Name Signature Month Day Year <br />...n <br />16. International Shipments ❑ImpU.S. ort to US ❑Export from U.S. Pod ofenhy7exit: <br />z <br />Transporter signature (for exports only: Date paving U.S.: <br />Ce <br />17. Ta nspoderAdmolvedgrnentofReceiptofMaterwts -' hfon0l Day Year <br />Transporter I. PdnlV! ed Name sig <br />O <br />z <br />TanspoMr2 PdnlediTyped Name Slgnalure "' �ManthOay Year <br />a <br />c <br />r <br />18. Discrepancy <br />18a. Discrepancy Indlcetion Space ❑ []Type ❑Residue ❑PaNal Reaction ❑Full RejeclJon <br />Quantity <br />Manifest Reference Number. <br />18b, Altemale Faclfdy (of (generator) U.S. EPA IO Number <br />7 <br />V <br />WE <br />W <br />Fal Phone: <br />18c. Signature of Alternate Fadlity(or Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Marled Codes (I.a.,codesfarhazartleus waste treatment, disposal, and recycling systems) <br />1, 2. 3. 4. <br />Hi—fi <br />20. Designated Facility Omer or Operator. Cedificetion of receipt of hazardous materials covered by themang8" except as noted In Item 18a <br />Printed(fyped ane Slg - Month Day Year <br />o <br />EPA Form 8700-22 (Rev. 305) Previous editions as obsolete. <br />DESIGNATED FACRITY S CO <br />