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<br />Form Approved. OMB No. 2050-0039
<br />EgPAg Form 8700-22 (Rev. 3-05) Previous4 ¢editiions are obsoi
<br />GENERAT®H'5 INITIAL UYVY
<br />UNIFORM HAZARDOUS 1. Generator ID Number ¢
<br />C,11-1,000 1 `)1�A')
<br />2. Pa e 1 of
<br />3. Emerlggency Response Phone
<br />1..-S�IO._4681760
<br />4. Manifest Tracking umber
<br />WASTE MANIFEST
<br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address)
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<br />Generators Phone: ecl
<br />6. Trans ortgr 1 Compaq __ Name U.S. EPA ID Number q
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<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />8. Designated Facility Name and Site AddressYA1� ID Number
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<br />17PP COOPER GREEK K ROAD
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<br />Facility's Phone:
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<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />No.
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<br />and Packing Grro{up� (f an�y))c
<br />Quantity
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<br />14. Special Handling Instructions and Additional Information Ski I P#a-VR f a J9 70 58061814 98800 MO.
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<br />SV .At ,.-fitt USE
<br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 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 labeledlplacarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary
<br />Exporter, I certify 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) (If I am a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Gec�eratgrslOfferoes PrintedlTyped Name Signature Month Day Year
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<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from11.S. - Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />17. Transporter Acknowledgment of Receipt of Materials
<br />Signature Month Day Year
<br />Transporter 1 printedlTypad Name
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<br />Transporter gpOtedfryped Name -"Signature Month Daay+. Year
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br />Manifest Reference Number:
<br />18b. Aitemate Facility (or Generator) U.S. EPA ID Number
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<br />Facilitys Phone:
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<br />18c. Signature of Alternate Facility (or Generator)
<br />Month Day Year
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<br />N19.
<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />1.
<br />2.
<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 />EgPAg Form 8700-22 (Rev. 3-05) Previous4 ¢editiions are obsoi
<br />GENERAT®H'5 INITIAL UYVY
<br />
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