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Please print or Noe. (Form designed for use on elite (12 -pitch) typewrler.) <br />�• Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 14. <br />Manifest TrackingNumber <br />JJK <br />WAST MANIFEST oiJo ,)/� ^Y�I <br />I <br />ur(iU 3 �- u�^, <br />001382429 <br />5. G I Name and MailingAiYd/ass Generators Site Address (if different than mailing address) _ <br />u T `�PGC;Joi?s" �yY�- <br />I.,vl,i:L <br />N�hone: <br />G S <br />iranapo�er <br />1 n ar2e U.S. EPA ID Number <br />411'( <br />OPI <br />r' <br />. ren n Name/ s'• U.S. EPA ID Number <br />t (� <br />4 <br />d Fara ar�+S drree��ss U.S. EPA ID Number <br />FsFM�ne Gr' /7 `7 �IJ / / Z <br />9a. <br />9b: U.S. DOT Description (Including Proper Shipping Name, Hmrd Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unci <br />13. Waste Codas <br />No. <br />Type <br />HM <br />and. Padang Group (d any)) <br />Quantity <br />W1.Nol. <br />a, <br />'`Y) / <br />1. 1,- ci,� <br />S P,od✓Cr%J <br />l r > q' <br />M, <br />�- <br />z <br />w <br />2. <br />c9 <br />3. <br />4. <br />14. steal Handling Inawgorn; aria Additional Information <br />cY3'Y l <br />L 27 <br />U%PQr P/'C' (�/ PPr v� ,, ✓i>c /72/0. GLJP r �i fS U"i7 % G�N r1 �S c.'. OJD/G k'/ P• <br />15. GENERATOWSIOFF ROR'S CERTIFICATION: I hereby declare that the contents of thisl;nmerd are ku accurately described above by the proper shipping name, and afe classified, packaged, <br />marked and laheleWPacarded, and are in all respects in properconditlon for transportaccording to applicable intemationaland national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contends of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) if I am a small quantity generator) is hue. <br />Geriaators/Ofierors Prnted/fyped Name Signature. --.. Month Day Year <br />S •.-`k—�Iz L <br />F <br />16. International Shipments <br />Import to U.S. El Export from U.S. Port of entry/exit: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: .. <br />W. <br />17. TransporterAdaawledgrnenl of Receipt of Materials <br />T I ft, tied" N "{ T Sig � Month� Day <br />I / ear <br />aponer 2 Nixtedrfyped Name wature Month Day Year <br />H <br />} <br />18. Discrepancy - <br />fila. Discrepancy Indication Space ❑ [uenlip, ❑ Type ❑ Residue ❑ Partial Rejectionfull Rejection" <br />Manifest Reference Number <br />18b. Alternate Facility (or Cxoneretor) U.S. EPA ID Number <br />J <br />U <br />LL <br />Faul,tys Phone: <br />W <br />1So. Signah of Alternate Facility(or Generator) <br />Month Day Year <br />Q <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, d4wat, and recycling systems) <br />2. <br />3. <br />4. <br />20 Designated Facility Owner or Operator. Certificabon of receipt of hazardous materials covered by the manifest except as Med in Item 18a <br />1 <br />PrftWyped Name Signature Month Day Year <br />G' <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />