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AB Bod Shop <br />Please print or type. (Form designed for use on at to 112-pitchl lvoewriter-1 <br />2^"4663771 p.3 <br />FnrmAnnrved_0Ml No 205D-Otl'i9 <br />EPA Fcrm 8700-22 (Rev. 3.05) Previous ealtions ar onspl it GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator IC <br />2. Page of 3. Emergency Response Phone <br />nifest <br />4. MaTracking Number <br />ImberI <br />WASTE MANIFEST <br />g J J K <br />A. G <br />5. Generalcr s Name and MaitingAddress <br />Generator's Site Address (ifdiffemnt than mailing eddressl <br />Generator's Phone: <br />6, Transperer 1 Company Name <br />-REGE1 <br />VFpU.S. <br />EP41D %nber <br />7. Tranaperer 2 Company Name <br />U.S. EPA ID Number <br />B. Designated Facility Name and SileAcdress <br />U.S. EPA ID %ricer <br />ENVIRONMENTAL. <br />Facility's Phorl <br />NFAI TW n;:V6 RTAACf\IT <br />g e_ <br />M. U,S. DOT Description (including Proper <br />hipping Nana, Hazard Class, ID Number, <br />0. Containers <br />11, Total <br />12. Unit <br />1:. Waste Cedes <br />Nc. <br />Typo <br />}.;A <br />and Pad6ng Group (H al <br />Quantity <br />'NtnJol. <br />a <br />1. <br />_ <br />QO <br />c <br />Z <br />2. <br />w <br />3. <br />4. <br />14. Special Handling lnsiructlons and Additional lnto <br />aiion <br />15, GENERATOWSIOFFEROWS CERTIFICATIO <br />: I hereby declare thatlhe comentsof Ihls consignment are fully and accurately described above by the proper shit name, and are classified, packaged, <br />marked and labeledlplecaded, and are in all <br />the Primary <br />pecW in proper coidition for transport according to applicable international and national governmental regulations. H export st#rent and I am nter <br />Exporter, i certify that the contents of this cons <br />ment coriorm to .he terms of the attached EPAAcknaededgmert of Consent <br />I certify tnat the waste minization imslatement' <br />nilfied in u) CFR 262.27(al (ill I am a large quantity generator) or (b) lif I am a small quantity penerator) Is true. <br />Genenator'sWaroes Prfnted/Pyped Nane <br />Signature Morh Day Year <br />.4 <br />� <br />16. Inieroalional Shipments <br />❑Import to <br />.S. Export from U.S. Patot entry;exll: _.. <br />K <br />Transporter signature (for exports only): <br />Date leaving U.S <br />W <br />17. TrarsporterAdmNmedgmeitof Receipt of Mata <br />s <br />r2 <br />Transporter1?nnle&7ypedName <br />Signature Month Day Year <br />O <br />CL <br />z <br />Transirorte• 2 Frimed?yped Name <br />Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Ircli on Space ❑ Clmanti <br />❑Type ❑ Residue ❑ °.root Rejection ❑ FLO Rejection <br />Manifest Reference Number. <br />18b. Memate Facilty (or General <br />U.S. EPA ID N.rmW <br />J <br />V <br />Facility's Phone: <br />In <br />lac, SgnatureofAlternete?aclily(or Generator) <br />Il Day Year <br />a <br />Z <br />ht <br />g. Hazardous Waste Report Managerran: MAW <br />"Odes ii e , codes for hazardous waste treatment, disposal. and recycling systems} <br />UJI <br />1 <br />3. 4, <br />20. De igreted Facltty, Ovmer or Operator. Ce. -K c9tit <br />n of receipt of hazardous materiels covered by the manifest except as noted In Item 1 &a <br />Prlmedffyped Name <br />Signalure Month Day Year <br />EPA Fcrm 8700-22 (Rev. 3.05) Previous ealtions ar onspl it GENERATOR'S INITIAL COPY <br />