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Please print or type. (Form designed for use on Mile (12 -pitch) typewriter.) <br />0 <br />form Approved. OMB No. 2000-0404. Expires 7-31-86 <br />Style F16-6 Labelmaster. Chicago, IL 60646 GENERATOR COPY EPA Form 870G -22A (3-84) <br />UNIFORM HAZARDOUS <br />21. Generator's US EPA ID No. Manifest Document No. <br />22. Page <br />Information in the shaded <br />WASTE MANIFESTareas <br />is not required y Federal <br />law. <br />(Continuation Sheet) <br />23. Generator's Name <br />4/— <br />L. State Manifest Document Number <br />M. State Generator's ID <br />23 Transporter Company Name 25 US EPA ID Number <br />N. State Transporter's ID <br />O. Transporter's Phon <br />26. Transporter Company Name 27. US EPA ID Number <br />P. State Transporter's ID <br />Q. Transporter's Phone <br />29. Containers <br />30. <br />- <br />31. <br />R <br />28. US DOT Description (Including Proper Shipping Name. Hazard Class, and ID Number) <br />Total <br />Unit <br />Waste No. <br />r <br />No. Type <br />WyVoI <br />777-,7--- —.— -7- <br />----QuantitX <br />3 <br />j". <br />V 7'-j <br />G <br />E <br />r <br />N <br />E <br />R <br />A <br />7— <br />T <br />0 <br />K-1 <br />R <br />h. <br />i. <br />S. Add— na1 DeViptions for Materials Listed�I� <br />e 4C <br />T Handling Codes for -Wastes Listed Above <br />A <br />32. Special Handling Instructions and Additional Information <br />J? <br />T <br />33. Transporter ��Acknowledgement of Receipt of Materials <br />Date <br />R <br />A <br />PrintecItTyped Name <br />Signature <br />Month Day Year <br />N <br />S <br />o <br />34. Transporter _ Acknowledgement of Receipt of Materials <br />Date <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />F35 <br />A <br />Discrepancy Indication Space <br />c <br />I <br />L <br />I <br />T <br />Y <br />Style F16-6 Labelmaster. Chicago, IL 60646 GENERATOR COPY EPA Form 870G -22A (3-84) <br />