Laserfiche WebLink
Please print or type. <br />Form Approved, OMB Na. 2060-0039 <br />EPA Form 8700-22 (Rev.12-17) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZHAZARDOUS1. <br />Generator ID Number <br />2: Pa�ye lot <br />3. g Emer Res P one <br />{ � IW :zs� <br />4. Manifest Tracking Number <br />g <br />WASTE MANIFE5T <br />ek�Cli9f :r;3 s �fi Cd <br />� �� � JJ <br />5�¢llprs Name and Mailing Address Generator's Site Address (if different than mailing address) - <br />ddress)1,3GON- <br />1,3 GO N -Ati :AR'8'#4'tA VV <br />r k" C"t L $"r' c <br />yy ggyy <br />Cenerator's Phone: <br />T r ojn a afire � U.S. EP;�D r�um�er <br />qy R fly, <br />NA S. S�;':k'l. k����i_.... I �...�A ROHA V.cS.'j ?gn <br />7. Trans orter 2 Com any Name U:S. EPA ID Number <br />8. Desi, naffed Facili�! Name and Site Address U.S. EPA ID Number <br />" . $ f a�*0VK11%Yr.A (., <br />V210 VENERNT WAD, ; <br />FRMOMA R.S. W36 <br />Facility's Phone: tov) <br />ga, <br />gb. U.S. DOT Descrlp(ion (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 />Quantity <br />WLNol. <br />�p <br />✓n. <br />�p p # y a s p <br />P41., IPTIPR3,. wP�:T.t Ch.:�Sk�'Y.gsiti%hir fAF�$�6�tl: g, PM.ii.."Y ��rY. Er ii:, r C-I-i.'r'}.�5.:'. r, 3, <br />O <br />g <br />h�'091 <br />q <br />.FIM <br />IrAa <br />V <br />4. <br />14. Special Handling Instructions and Additional Information <br />.yy �,"34��1.' � i;���0;�•4,�,tG :4,.�x���:�r#r.�xy�. `4�i�y'��ir`x�&�-7 <br />gg# A y� �,, g� E gp fy�0. �s p r.��yg4 �.�r gyp; y,� <br />���+}J@+�:rN�.5:&:. �y5b"igl�Ty+grti�.+.�r��5¢. o -t AppyrX'u.�,fyir <br />k�u�.w.C'a�k�Mrr�g.4'G.a:+...l.,.r»,,..,,,...,r,,....—a.,�:,..� ..... <br />rggky..d. <br />YDR-11"i.V �:1L' rVA1� 4 9A..�'"r.e�J� .GSA.",. .�7ir � .:R .iyl.i'NmY� } C.'li���i:6T�-Idnt? �4 �.Y�t �Qrj'#rv,VV <br />15 GENERATOR'81OFFEROWS 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 propor, condition for transport according to applicable intarnatioraland 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 EPAAcknowledgmert cf Consent. <br />I certify that the waste minlmization statement identified in 40 CFR 262.27(a) (if I am a large quantity gonera(or) or (b) (if I am a srrM quantity generator) is true. <br />-- <br />---- - Siln,_.- <br />Gone r tar'slDHeror"s Printed/TypedName ,�Month Day,+ Year <br />r y <br />� <br />� <br />_j <br />P- <br />16.InternationalShip mants <br />❑ I mport to U.S. ❑ Export from U.S. Port of entrylexil: <br />E <br />Transporter signature (for exports only): Date ieaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transportor 1 Printod/Typed Name Signature i ;t Month Day Year <br />3 s _ I-,�r%�`.�t..r,.rt,... f '''_;'., L. .}_ ,m�N�,n,.r+ ., Vw <br />Transporter 2 Pdnledrryped Name Signature 'F� Month bay Ye r <br />e0Z)y <br />18. Discrepancy <br />18a, Discrepancy Indication Space Quantity❑ T ❑ <br />Type Residue Y ❑Partial Rejection �. ❑Full Rejection <br />Manifest Reference Number: <br />18b, Alternate Facility (or Generator):. U.S. EPA ID Number <br />Facility's Phone: <br />iLir <br />18c, Signature of Alternate Facility (or Generator) <br />Month Day Year <br />z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ© <br />1, <br />2. <br />20. Designated Facility Owner or Operator: Cerlificagon of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br />Prinled)Typed Name Signature Mi Day Year <br />EPA Form 8700-22 (Rev.12-17) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />