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Please print or type,(Form designed for+use oh elite(12 pitch)typewriter) Form Approved,OMB No.2050-0039 <br /> UNIFORIN HAZARDOUS 1.Generator ID Numher 2.Page 1 of 3 Emergency Response Phone 4 Manliest Tracking Number <br /> ? a "132 JJK <br /> VVASTE PoINNIFE57 = I T"i E , <br /> one>stoa .Nafne and Mallin Address Ir yy T� <br /> RAI c� MST S T i Generator's Srfe Address(if different than mailing address) <br /> 7,w ?Qt9rr, 9.. E.1RAI Lrw ) i�l r e-- ai i r, .n;3 . 1 . <br /> 2016 APR 28 AM 10: 3 <br /> Generator's Phone: - U.S.EPA ID Number <br /> 6 Too nspoder l Company Name _ p F 0 7 - <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name - - <br /> 8.Desi net d Facility Neme and Site Address U.S.EPA 10 Number <br /> Facility's Phone 'moi ., c #Contalnersll. <br /> 9a 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) Wt.Nol. <br /> `rn5ra' U!" L3Lil _ . I i <br /> I I <br /> '-' Llrs ,hi•, . <br /> i ! <br /> I <br /> i <br /> 1 <br /> 4. i <br /> Lr4Oi <br /> "V rxv <br /> 14.Special Handling Instructions and Additional lnform�aijlop, O ? �Y7It ' l� al�it`1}'I �� <br /> �LTT ��dd1 LV9, <br /> One or � 1. <br /> In <br /> the <br /> l'Ia18,May <br /> Bere�Yc�e� n live daily cover S2p1idal'Itn'4, A Qth4P 4"! fy d 1 L e ?z�L <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION , Ve tars that the contents lefthis bbd'sigordent are fully and accurately descrihed above by the proper shipping name,are are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition far transport according to applicable international and national governmental regulations.If expert shipment and I am the Primary <br /> Exporter,I codify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that the waste minimization statement identified In 40 CFR 262,27(a)(if I am a large quantity generator)or(h)(If I am a small quantity generator)is tme. <br /> Generator ooff or's Printedlrypeit Name Signe ure Month De Yaar <br /> L L <br /> 16.international Shipments ❑Import to U.S ❑Export from U.S. Pod of entryleA: <br /> Date leaving U.S,: <br /> z' Transporter signature(for exports only): <br /> W 17.TmnspoderAcknowledgment of Receipt of Materials .. <br /> Transpode 1,,Pri ted/Typed Name <br /> Signature Month Day Year <br /> -L1410 <br /> ZTransporter 2 Printed(Typed Name Signature Month Day Year <br /> CG <br /> H <br /> 18.Discrepancy <br /> 1 a.DisFrepancy Indlcatlo pace '91 j ❑Full Rejection <br /> y o ❑Rgsld'ue / Pallial Reecion <br /> �j �f i1 11i�Qe �' 1 T i N(?wP. w1�J�3 � . S �9r ,fmi e C'oMe a�� � d <br /> It% 0 4( Manifest Reference Numher. <br /> 18b.Allemale Facility(or Generator) 0.S.EPA ID Number <br /> U <br /> ski Facility's Phone: <br /> w 18c.Signature of Alternate Fortify(or Generator) - Month Day Year <br /> d <br /> 19.Hazardous Waste Re'pto�rt Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1 1� 2 _ q 3. 4. <br /> 20,Designated Facility Owner or Operator.Cedkfica8on of receipt of hazardous materials covered by the mamf�except as ridged In ltze t8a nk month Day Year <br /> Prinfed(ryp d'Name ��^^ 7 tt J{� f Sri+ tA....a'.w`s,"`-•✓d 3 - '°" a� <br /> me t 1 t t._o <br /> FPA Form 8700-22(Rev.3-05) Previous etiflons are obsolete. DESIGNATED FACILITY TO GENERATOR <br />