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Please print or lvoe. (Form desioned for use on elite (12 -Ditch) lvoewriter.) <br />FormAooroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FA#ILITY TO DESTINATION STATE (IF REQUIRED) <br />W <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />��r� <br />CA -w000 (p CX/ <br />` <br />�` )_� __� _�_ , <br />018 6 814 7A J K <br />5. Generator's Name and Mailing Ad dr Can a j dd s <br />G -e66 o,U41 by <br />;jSitq,4wet, <br />III <br />Idlff�, <br />' 1j1 <br />r/�/� <br />� ` <br />� <br />Generator's Phone: 1 1 I�LJl VI7 "l�)l <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />zvLE::I'tiTE 1'H E(1ji:'irf �l'lEIF3E(VT :L <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />-'LEi�t.F'TECH El VIR.CNIt1EN TAE <br />GY.L0003-31_14 3 <br />IP'VVIND LE. v:4 91 706 LISA <br />Facility'sPhone: <br />ga <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. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />_ _ ._ _, .. , ... E.. Fii=E <br />0 <br />rT <br />Z <br />;,(' -_n,. -E <br />., ir. +S iF-S. _ 19 <br />2. -R _ : C.L ".. Ti. C. 9 <br />3. (i}y3 (il ?'5�1 FJ --!--;US VA.i3TE._'DL ILC I__E[e <br />.< <br />ISO <br />4. <br />14. Special Handling Instructions and Additional Information n, s 2- <br />,.-�i.f,.!R - 9 FE 6-4- USE -'-.L IVES AND -Gt . �G3LE•`3 T ANKEP*� <br />C,ki- ..EFF.' MUS -11T iDENTiFY CLE.='N T Er_H EttT.:•'i`.it(+)!-AEf''. ,.-%.L r._ (_:='-=`c.TE:P.I'�'T: I;;iH;,-�T4:; <br />15. GENERATOR'S/OFFEROR'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 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 uantity ge tor) is true. <br />Gener r' Offerors�ed/Type pme _ Signatur Mont <br />Day Year <br />-•r <br />z <br />16. Aer6a conal ShipmentsJ <br />❑ Import to U.S. ❑ Export from U.S. ort of entry/exit: <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />Or <br />17. Transporter Acknowledgment of Receipt of Materials <br />W <br />Transporter 1 Printed/Typed Name Signa t Mont Day Year <br />O <br />n <br />Cn <br />Q <br />Transporter 2PrintedFryped me Signature Mont Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q1Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />12. <br />3. <br />1 I <br />4. <br />20. Designated Facility Owner or Oper or: Certification of receipt of hazy ous materials covered by the manifest except as noted in I m 18a <br />Printed/T ed Name Signature ( Mont Da Y <br />YP g <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FA#ILITY TO DESTINATION STATE (IF REQUIRED) <br />W <br />