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1 ) 4 <br />Please prirttor type..(Form designed for use on e8te (12-Dffchl twewnbr l <br />Form AoDmved_ OMR Nn �nsrutma <br />EPA Form 97&22 Ten -M Previous edi6= are obsolete <br />-JDESIGNATED FACII:ITYTO GENERATOR <br />UNIFORM HAZARDOUS 1 Generator ID Number <br />2 Page 1 of <br />3 Emergency Response Phone4. <br />c)dnng Nur <br />Manifest Trambe <br />WASTE MANIFEST Cf+-irX.0-12 57 a a <br />0008 {, � - � 1 F L E <br />5 Gene�rattor's Name and Mailing Address Generamts Site Address (f different than mailing address) <br />tvr�) '+l 7 ;).�,_ 1 . �.. E IM-4•�c�1<r. <br />c:p�9i <br />P.0 .0 : 80X. r�01C t.iil . Z .fir{ i_w'-�M <br />s3i1*"i yr't"s ;�f�rc'i •ei r_. ��' 5 .r�rLrrt...t C' ryr= <br />Generator's Phone..9 Cid- " c .. u t s •� r. . u <br />6 Transporter T Company Name US EPA ID Number <br />7. TransporterCompany Name US EPA ID Number <br />+`2 <br />( qn <br />8 Designated FaaTdy Name and S11j Address US EPA ID Number <br />U'S Edi )°.1g.'r-. 7 d£"" •civ iiC:.^`.{i-'ts <br />S Elmore :dry:, ,:. <br />ga <br />Pa DOT Description (ndudmg Proper Shipping Name Hazard Class ID Number <br />10. Contakm <br />11 Total <br />12 unit <br />a9rbnd <br />HM !fig Group (ti any)) <br />Quantity' <br />wuv <br />T3 Waste Cedes <br />No. <br />nPe <br />f <br />1 �•f�i:.�`. irr:.�..^::A: �`:-`'Li:.. .t.,��?n �+-^-:i% - - <br />r <br />Al4:_ <br />Oma^ <br />1ji s <br />. <br />2 2 <br />us <br />It' <br />1 <br />.4 <br />s <br />14. SpedalHandling Instructions and Additional Information Fr, or <br />15 GENERATOR'SIOFFEiROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by cite proper shipping name and are ciasslfied, packaged <br />marked and lebeted8pfacarded, and are in all respects in proper condition for transport acrmrdmg m applicable international andr�r riofraTgaremmeriW regulations ff ex;at shipment and I am the Primary <br />Exporter, I ce" that the contents of this consignment conform to Bre terms of the attached EPAAcknaMedgmerd of Cdu� . <br />I certify ffiat the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (d I am a small gttentity generator) is Use. <br />GeneramrsfOfferors Nnteciffyped Name Signature.` <br />v <br />t <br />�£`: <br />�.?t'� +i. �Gi1�•>. �f'3• v! ► iv; :lei 77$>! 0$ s�zrl�'l�i-,fhr _ ,l'4. �•- �yr" <br />F- <br />16 intemational Sfgpments -� <br />Q Import to U S Export from U S Port <br />z <br />of erlUyle-At <br />Transporter signature for exports on 1 Date Jeav' U S- <br />17. TransporterAckiot0edgment of Receipt of Materials s t <br />Transporter 1 PnntecirTyped Name <br />Trdnsporter2 Pdrtted'/Typed Name Signalm t r <br />f fry)- r' (��� I ��` �•s{'✓I CJ�i• ✓�.. <br />`. <br />m <br />.18. Discrepaxy <br />189 Discrepancy Indcafion Space D Duentity ❑ Type 0 Residue ❑ Partial Rejection ❑ Frdl Rejection <br />Manffest Reference Numiber. <br />18b Alternate Facft for Generator) US EPA ID Number <br />,rte... <br />4 <br />LL; <br />074Gj <br />W. <br />Fa s Phone: <br />18c Signahsre of Alternate Facility (or Generator) MoNh Day Year <br />19, Kmwdobs VVMW Re* Management Method Codes (Le.. codes for hazardous waste treatment disposal, and reryc[ing systems) <br />97 <br />1 t 2 3 4 <br />20. Desonated Fadfity 0wneroyQperaor: Cw icabon of receipt of hazardous materials covered by tine manifest ermept }s noted in It rr,18g ' . <br />Prmt j�1jfypeld Nar Month yDaj)y Y <br />A..t� .^- is J` \ /. I !'�'/' _ I I L j f t) r• <br />EPA Form 97&22 Ten -M Previous edi6= are obsolete <br />-JDESIGNATED FACII:ITYTO GENERATOR <br />