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PI x9se Drtnt or Woe. (Fort desioned for usr, nn alitp 119-nifrhl tvnnu, t , 1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete GENERATOR'S INITIAL COPY <br />- - iviin r+NNiuvru VwiD IVU. LUJU-UUJZj <br />UNIFORM HAZARDOUS 1. Generator ID Number 2 Page 1 of 3. Emergency Response Phone 4. Man fest Tracking Number <br />WASTE MANIFEST -., ru>ir s -' 4 ? FLE <br />5. Generator's Name and Malting Address Generator's Site rd druss Qf dlffeisht-than mailing address) <br />..' 30Aiiia i411d111K Li4-6ft <br />"� �• � � ii��,�KK.C�fli <br />Ge actors Phone: •,.1 <br />ransporter 1 Company Neem U.S. EPA ID Number <br />-�cvcal Trarw4wIa (16W <br />1 Transporter 2 Company Nm US EPA ID Number <br />ROWWy Ste, kv <br />8 Designated Facility Name and Site Address U.S. EPA ID Number <br />- <br />1'r`•' <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Clam, ID Number, <br />10 Container,- <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (I any)) <br />Quantity <br />Wt.Nnl <br />13. walla Codes <br />No. <br />Type <br />LLI <br />w <br />2 <br />c� <br />I <br />i <br />1 <br />I <br />i <br />14. Special Handling Instructions and Additional Information <br />e_ rr +•'� �'�ttit,�; 1_id%lti2 1%(i�(A1dt3Clr� i.+i:?�iezi�� <br />VWWCAY <br />1-, GENERATOR'SfOFFEROR'S CERTIFICATION: I heruby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and lar udlplaarded, and are in all respects in proper conditOn for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contonls of this consignment conform to the terms of the attached EPA Acknowledgment of Consent - <br />I certify that the waste minimization stalement Identlfiad in 40 CFR 26227(a) (d I am a large quantity generator) or (b) (it 1 am a small quantity generator) is true. <br />—Name <br />Generator erors PrintedriyFfdi Signature Month Ny ear <br />J <br />I.— <br />16 International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit <br />z <br />frau; orter si nature (for exports only) ) Dale leaving U.S.: <br />uI <br />17 Transporter Acknowledgment of Receipt or Materials <br />Transporter 1 Printed/Typed Name Signature Month nay year <br />/Signature <br />Q <br />Transporter 2 Pnnie lltyped Name month I ay rear <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Spare ❑ Cluantity ❑ Typo ❑ Residue ❑ Partial Rejection Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) US EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />W <br />18c. Signature ofAltemate Facility Generator) Month Day Year <br />y (o <br />19. Hazardous Waste Report Management Method Codas (I e., codes for hazardous waste treatment disposal, and recycling system.) <br />C <br />1 <br />2. <br />3 <br />4 <br />20. Designated Facility [Avner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />PnntedrTvped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete GENERATOR'S INITIAL COPY <br />