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I <br />Please Print or Noe. (Form deSinnpd fnr ileo nn olitn rh—... � <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />" - ..— I Form Approved. 061B No. 2050-0039 <br />UNIFORM HAZARDOUS 1 GeneratorlDNumber 2 Page 1of 3. Emergency Respom Phone, 4.MilipfestTracking Number <br />WASTE MANIFEST �� <br />ars? Ma ling Accress J Generators Site Address V different than mailing address) <br />a % Na�ny aEI+VI tOnitlCA� <br />r� ai <br />155 1 Cafr�t/C4j CVs <br />r <br />Generators Phone: rr�� / L v-Itif <br />6. Transporter t Company Name <br />US EPA ID Nun Ser <br />.asporter 2 Company Name <br />U.S. EPA ID Number <br />Des9rtated Fa alrty Name and Site Address <br />U.S. EPA ID Number <br />lelnekrty RCGrt/risr� Zi1C- <br />Faolity's Plane: _ /t i ?G C 0.i t r trips • i r/ <br />33 <br />9b. U S DOT Description (including Proper Shipping Name. Hazard Class. ID Number. <br />Contmi-e's <br />ant <br />and Packing Group (A any)) <br />`dI <br />Un,: <br />�11t Vol <br />13 Waste Codes <br />Z <br />2. <br />NOMI +MCRA h.. �. ; i . , A- • <br />3. NON /ZCr A l�rs.Z.r;lav; +uaS a So/�c1 <br />4vNtpka waste <br />t -r <br />981; -31X!5561 I x3�u, tx �� ruby : Wx ray c <br />tbz: 3x556, <br />t/�5<.1 <br />15 GENERATOR'S,OFFEROR's CERTIFICATION: I hereby declare that the contents of this consignment are tuwty and accurately descnbed above by the proper shipping name, and are classified. packageo. <br />marked and labelediplararded, and are in A respects in proper condition for trarsport according to <br />applicable .ntemational and national governmental regulations. If export sh,pri and I am the Primary <br />Exporter. Ice(* that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) pf I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />GenermesOfferoes PrmkWTyped Name Signature / Month Day Year <br />J <br />Ir— <br />16. International Shipments <br />❑ Import to U.S. ❑ <br />Export from U S Port of entry'exd: <br />Transporter signature (for exports only): - -- -- <br />Date tearing U S <br />W <br />17. Transporter Ackrwwledgment of Receipt of Materials <br />cc <br />0 <br />Transporter 1 P ntedlTyped Name Signature Month Day Year <br />CL <br />V) <br />Z <br />'snsporter 2 PnntedTyped Name Signature Month Day Ye., <br />t— <br />Discrepancy <br />9a Discrepancy Indication Space Quantity Type ❑ Residue ❑Partial Rejection ❑Full Rejectwn <br />18b. Alternate Faality (or Generator) Manifest Reference Number. <br />J <br />U.S EPA ID Number <br />0 <br />LL <br />Faolry's Phone. <br />C3 <br />18c. Signature otAltemate Fadtity (or Generator) <br />Q <br />Month Day Yea, <br />Z <br />W19. <br />Hazardous Naste Report Management Method Codes (.e., codes for hazardous waste treatment, cisposal, and recycling systems) <br />0 <br />1. 2. 3, <br />T- <br />20.Designated Faolity Owner or Operaar Certification of receipt cf nazardo-.s ma'.enals covered by the manifest except as noted in Item 18a <br />nnted yped Name <br />Signature b',�1- Day Year <br />I i r <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />