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Please print or type. (Form designed for use on elit(12-pitch) typewriter.) <br />Form Abbroved. 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. Pag­e1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />1 C A L r <br />0 0 01 a 6 <br />1. <br />0.100-53-51. 505 <br />0 0 21 5 3 3 JJK- <br />5. Generators Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />AN, rpt <br />Generator's Phone: <br />6, Transporter 1 Company Name <br />U.S. EPA ID Number <br />E, <br />J <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated FacilJty Name and Site Address <br />U.S. EPA ID Number <br />M B0ytz AVE, <br />Facility's Phone: <br />9a. <br />91b. U.S. DOT Description (including Proper Shipping <br />Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />Wt.N0I. <br />0 <br />F.1 <br />LLJ <br />Z <br />tkAZAJRX1,74K <br />LU <br />bo <br />3. <br />4. <br />14. Special Handling Instructions and Additional Info rr <br />tab . on <br />pixv--AR 1)3 PP.01a I [IF, D by <br />I XR,/ SRI VM-'. Ya S, N+. OR I VhK a. 14 XVR�� <br />FP. f AT-,T�ER MtJ.ST r <br />I -8tJ T f rY I Al 41, VAR V SA A 3 P2f 4 1 STRW4 T <br />15. GENERATOR'SlOFFEROR'S 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 />)ects 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 consigi <br />iment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement id <br />nfified in 40 CFR 262.27(a) (ff I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offeroes Printed/Typed Name <br />Signature Month Day Year <br />, ar <br />International Shipments <br />0 Import to U <br />S.❑Export 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 Material <br />Transporter 1 Printed/Typed Name <br />Signature,,,' Month Day Year <br />0 <br />CL <br />fw <br />Cn <br />Z <br />Transporter 2 Printed/Typed Name <br />Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity <br />El Type D Residue El Partial RejectionEl Full Rej.cti,,, <br />Manifest Reference Number: <br />18b. Xtemate Facility (or Generator) <br />U.S. EPA ID Number <br />:3 <br />I- <br />Facility's Phone: <br />D <br />Uj <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />!7C <br />Z <br />a <br />05 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1 <br />2,1 <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />