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Ll <br />Please print or type. (Form'designed for use on elite (12 -pitch) typewriter.) <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 1 INITIA COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />hi <br />2. Page1 <br />Emergency Response Phone <br />'te <br />4. pk <br />Inrr <br />WASTE MANIFEST <br />. <br />Sdf } RR d4 <br />5. Generators Name and Failing Address Generators Site Address (if different than mailing address) <br />Rk'Vir <br />qq <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />A &. 0 a. ?w .: d i . F �,3 f_, <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facili{ty Name anggd , U.S. EPA ID Number <br />##Si.�te}{33Addre¢sys <br />Facility's Phone: r ' = 6 f 6e a <br />9a. <br />9b. U.S. DOT Description (including, Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1. ,gCx§`t-E' f : fEAg' Af 1."k) U >WASE, 3('l) Ll 0 ttvt%. #°i(. ,14:Y's01r-1G . 0f;r,). <br />1tt <br />O <br />4 Su-, V%Y t <br />s.. <br />, <br />'tyr <br />Yob <br />2. <br />I <br />�z <br />f <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />..s. ,, ia;,: , tj .,i --#i 1;..« #€. ,.F a €,d a.. ,: lirn °u l.t, s ,�€e:,: t,..,.s.t t.._ r.% rf,4.x .tf0, f1 <br />I� ;.tE 31tJe.,P,h';a`,.,x. l,t - id`s. i `t rt � � f• �.i .9i Yi`3 3F"..A F 9 k{�"' 1 a ri p <br />15. GENERATOR'SfOFFEROR'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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowledgment 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 />Printed/Typed Name signature Month Day Year <br />re—'6ratoes/OfthSrs <br />N` �. <br />l� - <br />16. International Shipments <br />❑ import to U.S. ❑ Export from U.S. Port of entry/exit' <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />t2Transporter <br />1 Printed/Typed Name Signature Month Day Year <br />aZ <br />Transporter 2 Pdnted(ryped Name Signature Month Day Year <br />h <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity 0 Type ❑Residue l? Partial Rejection ❑Full Rejection <br />rt r20 A <br />Mantfe <br />P <br />18b. Alternate Facility (or Generator) d. qp" Numtier <br />ERMIT/SEMM-t —;; <br />v <br />M <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste ReportManagement Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1 <br />2. <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 />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. 1 INITIA COPY <br />