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rlease m or". Fonn designed for use on elite 12- Act wdler' Form ror <br />UNIFORM HAZARDOUS WASTE MANIFEST 21. General ID Number 22. P e 23. Manff*M Trackln9 Number <br />(Continuation Sheet) cid '2 �!3I �2 <br />26. Generators Name ! J ( .J <br />OMB No. 2050 0039 <br />25. Transporter Company Name C�b0 <br />26. Transporter _ Company Name U.S. EPA ID Number <br />27a. <br />HM <br />27b. U.S. DOT Descdpbon (including Proper Shipping Name, Hazard Class, IO Number, <br />and Packing Group (deny)) <br />26. Containers <br />29. Total <br />Quantity <br />30. Unit <br />Wtivol, <br />M. <br />Waste Codes <br />No. <br />Type <br />C <br />QO <br />K <br />W <br />2 <br />W <br />rJ <br />32. Speclal Handling InsWchons and Additional Information <br />LLr <br />Fa. <br />d <br />33. Transoorter Adminwiedignnent of Receipt of Materials <br />PrimMIwMe Signs Mot, <br />v JI <br />Day Year <br />= <br />F <br />J <br />U <br />LL <br />W <br />Z <br />0 <br />N <br />34. Trens Mr AdmoM mem of Receipt of Materials <br />PAnfed?yped Namagceym <br />35. Discrepancy <br />36. Hazardous Waste Report Management Method Codes 10, codes for hazardous waste treatment, disposal, and recycling systems) <br />ay ear <br />W <br />O <br />-PA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STAT <br />(IF REQUIRED) <br />