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Male ol m mn r .,no Agency <br />Form Approved OMB No. 2050-0039 (Expires 93091) <br />Please print or tvoe. (Form desioned for use on efifaA62-oifch NDSIVAlfer). <br />00 G <br />N a <br />M LL <br />r"' a <br />m <br />H <br />Z <br />W <br />U <br />E <br />Dr <br />Toxic <br />DHS 8022 A (1 /88) / <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions a obso eta. <br />--------- <br />\. V <br />VO [NOT write rigiog Flirt Una f ( 1 r <br />Yell w: TSDF SENDS THIS COPY TO GENERATOR (WITHIN I/130 DAY <br />= enerator a US EPA ID No. murn sr <br />UNIFORM HAZARDOUS <br />2. Page 1 <br />Information in the shaded areas <br />Document No <br />WASTE MANIFEST {V1 I I I I <br />of is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />t.-/:- ,(.���,,n 5 <br />PPA37328 <br />B. State Generator's ID <br />G^ <br />) N'er1 i c C / " <br />4. Generator's Phone z ) "I <br />5. Tr <br />apo er 1pom ny Nam 8. US EPA ID Number <br />C. State Tran orter's 7 <br />D. Transporter'e Phon <br />/; 7 ., , Y <br />7. Transporter 2 C pany Name S PAI Number <br />E. State Transporter' ID <br />F. Transporter's Phone <br />9. pasignaled Facility Name and Site Address _ 10. US EPA/ID Number <br />G. State Facility's ID <br />H. acility a 'one <br />I { <br />ti it <br />12. Container <br />1 Tot I <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Unit <br />Waste No. <br />No. <br />I Type <br />WI/VOI <br />State <br />EPA ter <br />ECLIC-' <br />N <br />r <br />E <br />Stale <br />R <br />A <br />T <br />EPA/Other <br />O <br />R <br />C. <br />Stale <br />EPA/Other <br />d. <br />State <br />EPA/Oth,9r <br />J. Additional Descriptions for Mate 'ala Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />fy <br />15. Special Handling Instructions and Additional Information <br />18. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and <br />national government regulations. <br />If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br />to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment: OR, if I am a small quantity generator. I have made a good faith effort to minimize my waste <br />generation and select the beat waste management method that is available to me and that I can afford. <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />i <br />R <br />17. Transporter'l Acknowled'ement of a eipt dr Materials <br />A <br />Pnnted/T pad Name <br />Signature / <br />/ Month Day Year <br />1 <br />S <br />Ji <br />k2 <br />P <br />O <br />/8. 'Prifin'spolhier 2 Acknowi6cigennelft of Receipt of Materials <br />' <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />I I <br />L <br />1 <br />T <br />20. Facility caner or O rator Certification of receipt of hazardous materials coverby thi" anifeat exc <br />t as noted in hem 19. <br />y <br />Printed/ T ed Name / <br />Signature <br />Monthay &st <br />DHS 8022 A (1 /88) / <br />EPA 8700-22 <br />(Rev. 9-88) Previous editions a obso eta. <br />--------- <br />\. V <br />VO [NOT write rigiog Flirt Una f ( 1 r <br />Yell w: TSDF SENDS THIS COPY TO GENERATOR (WITHIN I/130 DAY <br />