|
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 />
|