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Please print or type. (Form designed for use on elit (12 -pitch) typewriter.) <br />Form Approved. OMB No, 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Nur <br />iber <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />1 <br />! <br />8 0 0 - 6 35 -. SO kv.3 <br />00%3,J,%A634 JJK- <br />5. Generator's Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />L <br />N.. FL P114AI, i)RIV' <br />1-,,0'*JTh CMINITER S"IrREPT <br />"A <br />9!" <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />t <br />7 Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />o2l L4.Pwr(yV—$F-'-, RGAL <br />—AN <br />Facility s Phone: <br />9a, <br />9b. U.S. DOT Description (including Proper <br />hipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />Wt.NoI. <br />13. Waste Codes <br />No. <br />Type <br />4 <br />LU <br />Z <br />2. <br />UJ <br />3. <br />4. <br />14. Special Handling Instructions and Additional Info <br />n nation <br />1. I , f! 4'1.' '.,3 1 )4,•-41-1 <br />PS.ACARWt; 0k0. 10 1-) BY:_ARY'AVR/ <br />-IBIPMR, ml VIP SlGINIATI.VRE; <br />I * FR CALLER MIST I <br />TT1'Y TAITIVAP (JSA A-': RZG.`ST;Z".r <br />"S/'OtERO'RSl <br />15. GENNATO CERTIFICATION <br />I hereby 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 labeled/placarded, and are in all res <br />Dects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consig <br />iment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement id <br />ntified in 40 CFR 2§;227(a) (if I am a large quantity generator) or (b) I am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name <br />Signature, Month Day Year <br />1;4 thA I <br />1 iJ 4-7 <br />J <br />I— <br />TO"InterfiNorlal Shipments <br />Import to <br />, <br />U S. 0 Expo'rt from —U -S. Port of entry/exit: <br />Transporter signature (for exports only): <br />Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name <br />Signature Month Day Year <br />0 <br />U), <br />/ �-, <br />ZorOr <br />2 Printed [Typed Name -- , , <br />I - , Signature Month U5y Year <br />< <br />Ce <br />Discrepancy <br />I18. <br />18a. Discrepancy Indication Space Quant't� <br />El Type EIResidue El Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />LL <br />Facility's Phone: <br />C3 <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />!R <br />Z <br />' !2 <br />U) <br />19. Hazardous Waste Report Management Method C es (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ <br />1, <br />2. <br />T— <br />4. <br />20. Designated Facility Owner o <br />of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name <br />Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />