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14 it • <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />• coW <br />Form Approved. OMB No. -0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO O%TtdTION STATE (IF <br />UNIFORM HAZARDOUS 1, Generator IID Number <br />Li4L000) g -7 <br />2. Page 1 of <br />3. Emergency Res rise Phone <br />14. 1111 Ile Tracking umbo <br />6 2 7 6 9 `7 33 <br />WASTE MANIFEST <br />I <br />866.3 -1-1222 <br />FI=E <br />5. Ge l' NIa�me and Mailing Address / Generators Site Address different man mailing address)) <br />'�"g^' of V.i(er (,s/,.I, <', cie5 <br />/ <br />!Sox- 291 00 133 er. Ti�rne. <br />ea 1 Zod; eA 1s'aLl 0 <br />Generators Phone: ZO 3 / ) , <br />. Transporter 1 Company Name U.S EPA ID Number <br />Adua,ixreJ G'l,ox 7.4�s eAleaOoo-7oSNo <br />,,c&l ,4 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />( <br />e( lc/" !rte -r s-v/ccS ii, o3 r.3Lz <br />e. Designated Facil'q�1' Name and Site Addr U.S. EPA ID Number <br />o�F Sa. Tose LLL <br />i <br />fAo.�io.s <br />tozl A3m-.yessxx poidd <br />6a.. Tosc , 6A 95133 <br />64 9 <br />1 <br />Facility's Phone: 1408- y r -o Dos9 N y'3 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Ung <br />13. Waste Cod <br />j <br />No, <br />Tye <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNo1. <br />i <br />0 <br />1' <br />. UN1263 SJ4.s4e- pro:..4-, 3 P6 "7t,' <br />, <br />^ <br />Door <br />oo3t <br />+�3 <br />Jc <br />yao <br />f <br />z <br />4 <br />W <br />3. <br />4. <br />14. Special Handling Ins iWons and Additional information <br />4, e14322832, et:c-9o/ <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consgnment are fully and accurately described above by the proper shipping name, and are classified, Paola <br />marked and labeled/placarded, and am in all respects in proper condition for transport according to apDliable international and national governmental regulations. If export shipment and I am Ne Prim <br />Exporter, I cer8y that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br />I artily that the waste minimization statement identified in 40 CFR 262.27(a) (g l am a large gantry, generator) or (b) (' I am 1 quantity 2!!!= true. <br />nerato eros PnntWffyped meIgn <br />re y <br />ear <br />A <br />o9 <br />i <br />16. International Sill <br />❑ Import to U.S. ❑ Export from U.S. Port of englexg: <br />Transporter si nature for exports only): Date leaving U.S.: <br />w <br />17. TransporterAcknowfedgment of Recei t of Materials <br />he <br />Tm ermiledityped Na kii MonthQ ay <br />Year <br />Q <br />Trenspoder 2 PrinteQRyped Namenature <br />g ay <br />Year <br />eA 1/0 1z <br />OF <br />♦ <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue. ❑ Partial Rejection ❑ Full R <br />Manifest Refer nce Number. <br />18b. Alternate Facility Generator) <br />(or U.S. EPA ID Number <br />J_ <br />LL <br />S <br />Fapli s Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day <br />year <br />a <br />z <br />h19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest exap noted in Item t8a <br />Ported(Ty arae SgnaMre Month D <br />C/ <br />year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO O%TtdTION STATE (IF <br />