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Please Dint or Noe. (Form desioned for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050 -OC EPA Form 8700-22 (Rev. 3-05) Previous editions are onsolete. DESIGNATED FACILITY TO GENEKA1 t UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number a �®��CJ �J� WASTE MANIFEST CAL 000 09 9;�r3'1—� 47 5. Ge erator's a a and M ' i g Add r ss l Generator's Site Address (if different than mailing address) t r� Generator's Phone: 6. Transporter 1 Company Name " U.S. EPA ID Number FAi§ CJS S4i•:ViGE'S 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number i'.�^<i_�s._t.i'•nRG1�1Fr;Eli�..:SE"��.,G,: 11515 Sr;. RIVER ROAD ` Facility's Phone: 41:3-3. 1-5-7 7 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WtNol. 1• ?IJU�f~ti:P*:Y, i'#,a,�al`3.•i1.Ul_�� 4,-,t E SQLIQ�il kAl.i -��?UD'S�i a3 35 S ! � 'yrs �..._..,._;.,..__.._..... Z 2. t rL . 3. j I 4. 14. Special Handling Instructions and Additional Information _ERS TID BE TFMVEDO 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and 1 am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (f I am a small quantity generator) is he. Generators/08eror's Printedfryped Name �Si9nathrn r' Month Day Yea - a 16. International Shipments❑ 1 S Impo to U.S. ❑ Export from U.S. Port of entry/exit Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgmept of Receipt of Materials Li Transporter i Prihtedrrypa Name } i Signature f z" Month Day Yea z Transporter 2 Printed(ryped Name Signature Month Day Yea a 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ V ti Facility's Phone: LO 18c. Signature of Altemate Facility (or Generator) Month Day Ye Q Z y19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) W 1 2. 3. i'i1VY�cviitiLHEALTH 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name ) Signature i� Month Day Yea EPA Form 8700-22 (Rev. 3-05) Previous editions are onsolete. DESIGNATED FACILITY TO GENEKA1 t