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Please nrinl or Won- (Form desioned for use on elite 02-nitchl tvnewriter.) Form Annroved. OMR No 205041039 <br />:EPA Fprm 8700-22A Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />Generator ID Number <br />22. Page <br />23. Manifest Tracking Number <br />(Continuation Sheet) <br />121. <br />i <br />24. Generators Name <br />U.S. EPAJD,Number <br />25. Transporter Company Name 1 <br />U.S. EPA ID 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 />r. <br />_.. <br />,_.._._—_._I_------...-. <br />.............. <br />__1__,----.-.-- <br />32. Special Handling Instructions and Additional Information <br />33. Transporter —Acknowledgment of Receipt of Materials <br />F <br />Printed/Typed Name Signature Month Day Year <br />a <br />Z <br />34. Transporter Acknowledgment of Receipt of Materials <br />Printedlryped Name Signature onth ay ear <br />F— <br />35. Discrepancy <br />U <br />3 , <br />LL <br />O <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 />rn <br />W <br />0 <br />:EPA Fprm 8700-22A Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />