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Please prial or type. (form designed for use o4 elite (12 -pitch) typewriter.) <br />Form Amoved. OMB No. 20500039 <br />FPA Form 8700-22 (Rev. 3-05) Proviouseditions alreobsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1• Gene(alorl <br />Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST `: 0 D `;; <br />3 20130 2 11 <br />012422Qa5 JJ K <br />5. Ggg7p r __ p and.Ma3 ( <br />Genetator's SiteAddrau (Mlerent than maMq address) <br />ri);)T{' ILL �� 81 <br />1.0M i ('f�Si'�'.A4_' a JM E jM ;a <br />r-,O.-E'si1,),E <br />CA a5747 -S TCA'", 0R <br />Generalofs Photig., 203 v42 <br />622-1 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA 10 Number <br />8.Des.�gnatedFeuS NameandSAoAddross <br />U.S. EPAIDNumber <br />17K DI :MN <br />7300 CkFVRI-NN WA,r <br />DI;tOR <br />t: S Sr r=:' UP <br />Fatfity<s Phone; <br />9a. <br />eb. U.S. OOT Oescri*n (ndudA Pnq <br />u Sh'ppag Name, Hazard Class, lO Number, <br />10. Conla'ners <br />H.T0161 <br />12. Mi <br />M. Wu%Codes <br />No. <br />Type <br />MI <br />and Pack r q Group (if a ny)) <br />Quantity <br />WtMt <br />,e � t1 Cxt-' <br />`� ti•�t�'.;Tc, E. �i',1? l`,i„t. 0 1 <br />3q S' <br />z <br />W <br />2. <br />I <br />3. <br />r <br />14. Special Handn91ns(ructionsand Additfarai <br />Nal <br />14 1:_, o,.iiy-!I_ <br />.i}. .! .J EF .'..1._: __i:l_ t <br />s� K:' y? r�'/+.t iy{4T �-; 3,a 1<•y24-5?.0 ADSI`,: <br />f T �:J� �. 1,i 1J:� L �•Lf<!-i l'ai a�.i{•,t ': ��I'-[!", •r. l• •���i(lGV -•�V�/ 9 �Jv <br />ADOIMHVIA. EPA:11.Crt)I:S. ':,-; i • , N04F :; AP?ROPRI M E - CIERSONA <br />It <br />?)1JII,n FM"r <br />l D3� <br />15. GEIIERAToR'StorFEROR'SCERTIFICATI <br />N:Ihetfbydedarethatthecontentsofth:sconsgnmenlarefu'yandaccuratetydescnoedabovebytheptopersK-gpngname,ardarodassftd,packaged, <br />marked and labelap!acarded, and are in a9 <br />espects in proper cordal for transport auord!ng to a*cab'.e intemationaland national governmental regulations. II export sh pment and I am tho Primary <br />Exporter, I rariity that the contents of this <br />gnment conform to the terms of the attached EPAAderahledgment of Consenl. <br />Ice tify that the wasto m'n afon sratemen <br />tdesVed In 40 CFR 26227(e) (I1 am a large quantity generator) of (b) (dl am a small quantity generates) is We. <br />Genefator' Offeror's Print edR ame S gnature Lµ� � Month Day Year <br />11 __ <br />16.International Slgpmenis ❑import U.S. ❑Ey pad from U.S. Foilo(enWa)k <br />Transporter s!gna;ure (fo(exports ony): Date leaving U.S.: <br />04 <br />17. TransporterkkwA!edgmentolRece`ptofflett' s <br />CCTransporter <br />Nalme Signature Month Day Year <br />1 PrinledrTyped <br />) �t <br />IL <br />Transporter 2 Print 01ped Name Synature I..onih Day Year <br />18. asctepancy r <br />18a. Discrepancy kWabon Space R s al <br />❑ (ty ❑Type drue Pad'a1 Reeckn ❑ Ful Re;ectron <br />I R kr c �8lr. <br />l8b.AlarnaleFac+'ty(of Gerrera!or) U.S. EPA ID Number <br />� <br />HEir7 <br />Ua. <br />Faatys Phoro:r=WNjiBnNMENTAL <br />Q <br />18C. Signature orAllefflats Fadity (or Generator) c � ('t` <br />DEPARTtVr� 11 <br />Maxis Day Year <br />Z <br />y19. <br />Hazardous 45 stu t �t hrd Codes (i.e., codes for hazardous waste Treatment, dsposai, and iecy�ding systems) <br />3. <br />4. <br />Z0. Das�nated fao� ty ner or OP tor, C on o(rtce`pl of ha s materia's mvered by Ne maniest except as rKi IOi <br />Prin!ed7Typa ' nre r SgnaWre r Day Y r <br />! \l <br />� � �� � I. - <br />FPA Form 8700-22 (Rev. 3-05) Proviouseditions alreobsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />