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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 20500039 <br />EPA Form 870022 (Rev. 305) Previous editions are obsolete. 1 It <br />1. Generator ID Number 2. Pa e 1 of 3 Emer enc Res ose Phone 4. Manifest TracEn Number <br />UNIFORM HAZARDOUS 9 9 9 9 <br />_ j ��� <br />WASTE MANIFEST f/ A G 0 (1 (lA I !J a 2 (t .i ul(0i ?P9 i>300 '�. 7 + �.. <br />t;ta <br />1'Y <br />, r , :l) <br />5. Geators Site Address than ma Trig address) <br />{ala ne Name Ind +d lin AO��lf Gener(d d <br />3h <br />IJ U6 1 IfAr <br />r.19r, - "rL 11 I k/;NfT <br />J01t�/ <br />19 h; 1J.4P4N.iEfi I"I! <br />Generators Phone: <br />6. Trangser1 an N U.S. EPA IDN Number <br />i, eA <br />VI t113 <. (-�1��Y0Ni4I fl fA3_ 6dIGGS (; A f) O 111177F7 <br />7. Transporter Company Name U.S. EPA ID Number <br />8.Dasgnated �so Name and SiteAddress U.S. EPA ID Number <br />, <br />VW)f C 11 I, hl't;1'L1 1TI(I <br />;00011. Al )VM T F)A l f I N- V I <br />cf)MPWill r;q ,o..c>> <br />C dl T t3 iJ () tl 'i_ 3 <br />,, ,, ,. <br />Fa6hysPhone: (31O)F;9'/-7:1.(10 <br />ga. 9b. U.S. DOT Desorption unciud ng Proper Sh'pprg Name, Hazard Gass, ID Number, 10. Containers 11. Total 12. Unit <br />13. Waste Codes <br />Ht4 and Pacdng Group (if any)) No, Type Quantity WIMol. <br />CiOPdRi;fA1 rN1kf)VIJ- °'AI`ii1, 1foilill( 1tr+Kl fill)) <br />a <br />.. <br />z <br />2. <br />W <br />0 <br />3. <br />4. <br />14. Spedal Hand"ng Instructions and Additional Information <br />I f,draU: f,Wity Wf`IT7;U4 Gbl[f�jI IWC I IWO JIt% 1 1"V)0 V'); , i 0,1ifI 1Af.Al I U QVC 11liS I!"LIiolfl91li ; 7.'11, 1 RO1911";'{ 9k l : <br />I .31.91. G;Rf1FtE I HIIf) n TN'01141MF PS'E I quit AI—Jif <br />..tp il <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this oonsgnmenl are fully and accurately described above by the proper sh'pgng name, and are dassiged, packaged, <br />marked and Iabe!edlp!acarded, and are in all respells in proper condbon for transport accordng to aWicab%international and nat'onal governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of ms consignment conform to the lama of the attached EPAAcWMedgment of Consent. <br />1 certify that ihewaste m'nim'¢ation statement identd»d in 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (dl am a smal quantity generate) Is We. <br />GegeralorslUHerors Printed/Fyped Name Signature I,!om h Day Year <br />..� <br />1- <br />16. International Sh'pments <br />❑ Impel to U.S. ❑ Export from U.S. Port of entrylemt: <br />Transporter signature (far exports only): Date leav'N U.S.: <br />w <br />17. Transporter Acknan",edgment of Reoapt OfMataria's <br />Transporter 1 Prinlecli Name -: - Sigm dufe Month Day Year <br />n <br />4 <br />Transporter Pdntedflyped Name <br />Signature P,WN Day <br />Year <br />h <br />18. Dwepancy <br />I <br />18a. D;wepany Inds 5m Space [IQuanti ry Type Res.Nue ❑ Parts]Reedbn ❑Full Rejection <br />ldanifest Reference Number. <br />lith. Alternate Fadiity(or Generator) U.S. EPAID Number <br />J <br />Faa+ty's Phone: <br />w <br />18c.Signalure ofAltemate FaoTty far Generator) <br />Month Day Year <br />zz <br />N19. <br />Hazardous Waste Report Management Mati Codes (.e., codes for hazardous waste Vestment, disposal, and recldng systems) <br />4. <br />20. Designated Faatity Omer or Operalor. Certification of receipt of hazardous materials oovered by the manifest except as tided in Item 19a <br />PMtedffyped Name Signature l,Wth Day Year <br />4)y P. <br />t;ta <br />1'Y <br />