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Please print or tvoe. (Form designed for use on elite (12 -Ditch) twewriter.) <br />Form ADDroved. OMB No. 2050-0039 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />21. Generator ID Number <br />22. Page Z <br />23. Manifest Tracking Number <br />(Continuation Sheet) <br />C# C 0 0 11 <br />7 <br />Q 10 Lg9 0-7SK <br />24. Generator's Name ce f T` p _.,{ 4lAit ��nd W %Ck, oan� <br />C�©i' <br />% 1 <br />47,57 <br />Gf <br />U.S. EPA ID Number <br />25. Transporter Company Name '�;'q ) fii �i v J1 d <br />t1 <br />Number <br />26. Transporter Company Name <br />27a. <br />27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />28. Containers <br />29. Total <br />30. Unit <br />31. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />O <br />w <br />z <br />w <br />O <br />i <br />32. Special Handling Instructions and Additional Information <br />33. Transporter Acknowledgment of Recei�t of Materials <br />w <br />PrintedlTyped Name Signature ^ Month. Day Year <br />a <br />z <br />34. Transporter Acknowledgment ecei t of Materials <br />Printed/Typed Name Signature Month Day Year <br />H <br />35. Discrepancy <br />J <br />V <br />Lal. <br />0 <br />w <br />a <br />36. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />z <br />C9 <br />U) <br />w <br />0 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />