Laserfiche WebLink
Please print or type. (Form designed for use on elite (12 -pitch) typev nter.) Fonn Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous adibcr obsolete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />i. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phan <br />e. Mani1W Tracking NNunbw <br />,, n <br />6 3 314 G B F <br />WASTE MANIFEST <br />Al;,,. , .. <br />J <br />5. Generators Name and Mailing Address GeneralWs Site Address (it different than mailing address) <br />dt M)AUIDI RE'-3h.*lk IRAtJ¢J i' <br />-: i10X til 1 to Itl i'�1311Nt1nAY <br />KK)N ;'A (f:ssit ';Vjif M. TyN1 !:A %IS !Q'2 <br />Gelleratnr9 PipM: .. <br />6. Transporter 1 Cmrpny eros U.S. EPA ID Number <br />Alai. ii:i-+t: YAL l ! i vVA:a t_ Vii ifvC: i'al. t IiA1t3:!: 5/9 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated FaaNy Name and Site Address U.S. EPA ID Number <br />. �-:: c:LN IITH'i iNViRONIMENI AI 111116M 14 IN VAL•A Ili. nN!t<xBFlbytA�..UI <br /><11N51NEWI.ANU1i i.:R i <br />F F,hOR F.1' t1V 4$14411 <br />Fatil' sPtnne: .' --76. :.';''Jl <br />9a. <br />9b. U.S. DOT Description pncludhg Proper Shipping Nam. Hazard Clan, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Padp19 Group (I any)) <br />Ouantly <br />WINd. <br />IX <br />1. <br />Ii fl- RC, RA i IA ARU(AI-'i WA:, IF I tQLAI) <br />r <br />iF✓ <br />z <br />.4b:F2R•JF. '•i•i FIFF!FEIE G(il Uit['uaf <br />�p <br />' r <br />0 <br />� <br />w <br />2- N 'KI4AFIA ZA4 (�/r`r� A ,J <br />3. <br />d. <br />10. Speclal Handlig Insbuctau andAdditonal Informabon <br />PRUF 11 F. x 40404 1) 0 <br />15. GENERATDR'SIOFFEROR'9 CERDFICATION: I hereby declare tat tin contents of flus consgnment are fully and accurately described above by the proper shipping name, and are rlassifed. pad aged. <br />marked and IabebdlptereNetl. and are in all respects in proper oediton for transport according to applicable international and national grnmmmental regulations If export shipment and I am to Priory <br />Exporter, I ceN1y Nat the contents of the consignment conform to the temp of the attached EPAAdmowiedgmal of Consent. <br />I carty Nal rte waste minimization statement identified in 40 CFR 26217(a) (it I am a large quantity generator) a (b) (t I am a ental quality generator) is true. <br />Generatorsi08erois Printd(Typed Name sign" ._ h Yger <br />-11 <br />F <br />16. International Shipments <br />❑ Import to U.S. ❑ Expon ham u.S. Pat of entryledt <br />= <br />Transporter sgnatrm Por exports only): Dab leaving U.S.: <br />17. TmraMterAdmmv"Tem of Recsipl of Ma*kk <br />r>: <br />T �y,Peedd SWa n <br />Transporter 2 PrmtedlTyped Name Sk, Or— Month Day Year <br />C <br />18. Discrepancy <br />I <br />lat. OLonspancy Indiratm Spare ❑ Quantity❑ T� ❑ Residue ❑ Partial Rejection ❑ Fug Rejection <br />Manifest Reference Number. <br />18b Alternate Faolfly (a Generator) U.S. EPA ID Number <br />J <br />U <br />I <br />Faality's Phone: <br />W <br />18c Signature of Alternate Facility (a Generator) <br />Monty Day Year <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Meted Codes (i.e., codes lar hazardous waste oeabnem, disposal, and recycling systema) <br />C <br />1. <br />2. 3. <br />1. <br />20. Designated Facility Owner or Operator Certification of receipt of haraNas materials covered by the mantles) except a noted in Item last <br />PrintedlTyped Nana Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous adibcr obsolete. <br />GENERATOR'S INITIAL COPY <br />