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Please print or type. (Form designed for use on elite (12-pi(ch) ipewiiler.) <br />Form Approved, OMB No, 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. - -- - DESIGNATED t"daCBUITYT9 GENERATOR <br />UNIFORM HAZARDOUS- <br />1. Generator lD Number <br />2. Pagel of <br />3. Emergency Response Phone <br />4 Manifest Tracking Number <br />WASTE MANIFEST <br />QP DT S } u:., 2 0 " 4 <br />_. <br />f ``£3} r2~^ t;30J <br />z J3 ppm <br />3 <br />f® <br />5. Generators Name and Mailing Address ` Generators Site Address (II different than mailing address) <br />UEP 04TV'S V)7 1163. <br />3a 1, 0='x4'1e.s r� f :Ti.£, 5 <br />N <br />li5,;i'?i 1,.:_'.T.:; -�£ . <br />? n <br />Generators Phone: „ ,h)'c.t� •�?:'Z:'(.tJ' <br />6. Transporter) Company Name - U.S EPA ID Number <br />WO LD €`t; L rNIAR WCAWIMITAk...; $ ft t. p: 0 Ft : O 3 <br />,. , <br />7. Transporter 2 Company Name <br />43, EPA ID Nmnber <br />8. Designated FacilityName and Site Address - 4S, EPA ID Number <br />yG <br />Facilitys Phone: ('_:?�'P r"� :):• .5 <br />qz <br />9b. U.S. DOT Descriptlon(including Proper Shipping Name, Hazard Class, ID Number, <br />1o. Coolabmrs <br />11. Total <br />12, Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WI.NoI. <br />13, Waste Codes <br />No. <br />Type <br />y wu�q `=i B"I.� Y 13,!,] y.. 9 _ t'S_'_, e quf Z (WJ I1 .�ij <br />K <br />0 <br />0-1 <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions andAddigonal Information <br />vv <br />('e3EV MTV Ct�'S At t I _ {Ct8 <br />} '.r` - %r., C3L . - RIAL: s (til CR IPP F;Yfgivi:'il(, Pi f`+,;t;ip.i I (R4M'W1 V.. <br />r;6-eta:~.,n, OYCd TRUCK ��.....��'�. <br />.:vAOUT %V <br />15, GENERATOR'SIOFFEROR'SCERTIFICATION: 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 respects In proper condition for Transport according to applicable International and national governmental regulations. It export shipment and I am the Primary <br />Exporter, I cagily that the contents of this consignment conform to the temts of the attached EPAAcknowledgment of Consent. <br />- I comy that the waste minimization statement identified In 46 CFR 262.27(a) (if I am a large quantity generator) or (b) (if i am a small quantity generator) is We. <br />Generalorsl0 erors Pnntedrryped Name Signature / - - Morglh Do Year <br />e g1 <br />J <br />16. International Shipments <br />El import to U.S. ❑Export from U,S. Pod <br />z <br />or entry/exit: <br />Transporter signature (for extends only): Dale leaving US,: <br />w17- <br />Transporter Acknowledgment of Receipt of Materials .0 <br />Tmprypor)1 Pgn(e§dQyped Name. - - Slgnalu p Mor�In Day- Year <br />CZ <br />4 <br />Transporter 2 Pdnied7ryped Name <br />"Sig eture - - Month Day Year <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type 1:1 Residue ❑ Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Fadllty (or Generator) U.S, EPA ID Number <br />J <br />U <br />ra+. <br />Facilltys Phone: <br />w <br />18c, Signature at Alternate Facility (of Gunrunner) <br />Month Pay Year <br />a <br />z <br />m19, <br />Hazardous Waste Report Management Method Codes (i.e.,codesfor hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. 1 - <br />2. 3. <br />4, <br />F'b, int <br />20. Designated Fadlity Owner or Operator Cemficalimnof receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />Printed7ryped Name \ Signature Month Day Year <br />, <br />r2 i4k}, <br />VIII' <br />