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Pi.— nrim nr wrip (Fnm) designed for use on elite (1 2 -pitch) typewriter.) <br />FormAnoraved- OMR Nn qn.M.nwio <br />EPA Fomi 8700-22 (Rev. 3-05) Previous editions are Obsolete. <br />DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIR46) <br />UNIFOR41 N DOUS <br />=MANIFEST <br />1. Generator 10 Number <br />2. Pap I of <br />3. Emergency Rosporise Phone ITMOUR <br />Tracking Number <br />WASTE ST <br />I <br />001C. <br />0019829 <br />-SKS- <br />5. (;on ratVs Name and Mailing Address Generators Site Address (it diffemnl than mating address) <br />ij X. <br />Generals Phone' <br />—mr. alne. U.S. EPA ID Number <br />!r I Copipay. Norio. <br />7. 1tanspbd&r 2 Company Name a U:S. EPA 11) Number 70 1 <br />ri &)Q off <br />8.Oesgnated Fack Name and Site Address AF ET i, PE 111 :;'1r;) `i' E j) i I) -.:t tj U.S.EPAIGNumber <br />R H'Y' P OA ED <br />MAN, <br />rac4it Is Phone: <br />go. <br />9b. U.S, DOT Gescliption (including Proper Shieping Name, Hazard Class, 10 Number, <br />10. Containers <br />�l <br />ii. Total <br />12. Unit <br />No. <br />Tye <br />HM <br />and packiq &m* (if any)) <br />oualifity <br />wtivol. <br />13. Waste Codes <br />Y TZ", tlAilMABLE I 1.11H I ')SO - <br />0 <br />t ir0uI <br />2. <br />3. <br />4. <br />14.SpodalFRnd­1i(;lnsl ctionsandAdditionallnionnation <br /># 31 7 <br />L <br />(,:A PRIER' 10 <br />15, Gi—NEaTDR'SIOFFEROKS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately' described Wve by the proper $10fOng name, and are classified, packaged, <br />madred and loWed/placarded, and are In all respects in proper condition for transport according to applicable international and national gommerrial regaiations, if export sifipresni and I am the Primary <br />Exporter, I ceft that Ina, contents of hs consignment conform to the term of the allched EPAAcknmyledlitnient of Consent, <br />I carlity that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (I I am a small quadV generator) is he. <br />Generator Prinled/Typed Name Signature Month Day Year <br />6 (-L — I :��> 10,517-11091 <br />-j <br />F-- <br />- -111,11, 11 <br />16. International ShomefluS Em- from U.S. Porlcifonlryfe�it. <br />0 linpod to U.S. E <br />Transporter signature (for exports only): Date leaving U.S.: <br />w117. <br />Transporter Receipt of Materials <br />00CVL) <br />Transw a..nypedl4r- kue 2Month Day Year <br />14 0! f <br />112sa/ 10 9 <br />Transport 2pnoteav Name Signature Month Dak Year <br />1C, <br />Z. -rleZ. n &0 r 07 <br />18. Discrepancy <br />18a. Disaepancy Indication Space 0 'awntity, F—]Type El Residue L1 Partial Rejati. Full Rejection <br />Manifest Reference Number: <br />1 8b. Alt emate Facility jo r Generator) U.S.U.S.EPANumber <br />Facility'sPhone; <br />0 <br />18c, Signature of Allemal(i MAY (Or Generator) <br />month —DW —Year <br />19. Hazardous Wa sle Report Management MelhW Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />MUj <br />L2. <br />f . <br />3. <br />4. <br />—AW <br />20. Designated Facily Owner or omlor: Certification of receipt of hazardous materials covered by the manifest except as noted In It <br />d(TypedAe— — -J--- <br />I A <br />i a �;T, AA�1 <br />. th <br />EPA Fomi 8700-22 (Rev. 3-05) Previous editions are Obsolete. <br />DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIR46) <br />