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.)cilC',Ci`i �1 it - t. ,}fir`{: <br />Please print or type, (Form designed for use on elite (12•pilch) typewriter) <br />Farm Approved, OM6 No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. -� DESIGNATED FACILITY TO GENERATOR <br />�� i <br />UNIFORM HAZARDOUS <br />ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. MkanifeessttTrackkinng Number <br />STE MANIFEST_ <br />LGenenitor <br />'� '1 *:i <br />- 1�{ 6 a5 <br />{ ec <br />8 I l' FL <br />.3 <br />E.i . <br />S. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Pon tl rytwt.' on <br />22.01i WmWm w Aw, <br />8toc Otani <br />Generator's Phone:TQt} <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />_ <br />7 Transporterk Company Name U.S. EPA IDNumber <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Wffloi <br />°( IM R A �"�ta� <br />4,mWte, ff 84 <br />Facility's Phone: ar9- <br />9a_ <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />HM <br />and Pack}iingg ((if any)) <br />Quantity <br />WtNoll <br />13. Waste Codes <br />No. <br />Type <br />%GroS�upp� <br />11 a!'k�Li I t i��+4iti �5f 6h+� 1�bL�iLs iSi1�:.Sk ffiR.t'gr4Srk i""��d[;F���'E!k .^a t+4ci�aP���v�� <br />Tia <br />H'�� <br />�� [s`�livftr <br />3r7�) <br />j.741'.i <br />VD-- <br />---- <br />z <br />2. <br />rs <br />LU <br />I <br />3. <br />4. <br />r <br />t <br />14. Special Handling Instructions and Additional Information ^� y <br />43rot Mmil.1ar 91EW G *trm 3Etk: W016 k <br />:r:S ; �{? �✓� <br />rS;, tai��i�._ tC�;ti^+i(!'t,'r1)tj1 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and am dassified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. If expert shipment and I am the Pdmaty <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAcknovriedgment of Consent. <br />I certify that the waste minimization statement idenli(ed in 40 CFR 262.27(a) (it t am a large quantity generator) or (b) (if t am a sTfi Auantity generator) is true. <br />Generator'stOfferoes Ptinted/Typed Name ,. ." a (ac - Signature ,. Month ay ear <br />�'�=K.i r✓ S'��/i � ��� t. t��_'r✓..-v....N'�.t {i �.l 1_-�', <br />�'4� ��ai .�,.••�.. Y.:�/L� <br />J <br />16. International Shipments U.S. Porl <br />❑ <br />1- <br />Import fo U.S. Export from U.S. of entrylexiC <br />z <br />Transporter signature (for exports only): Date leaving U.S <br />LO: <br />17. TransporterAcknovrledgment of Receipt of Materials <br />Transporter 1 PrintedtTyped Name wtgnalu� Monthay Year <br />CL <br />Z <br />Q <br />Transporter 2 Print diTyped Name ignalure �{ Month ay Year <br />! <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity Typo El Residue Q Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S EPA ID Number <br />U <br />eQT- <br />'s <br />Facilit Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />R <br />Z <br />CD <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Ovmer or Operator Certification of receipt of hazardous materials covered by (he manifest except as noted in Item 18a <br />PrntedliypedName; "t �'"...I Month rlQay Year <br />i Signature r+ <br />{ <br />zz ,1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. -� DESIGNATED FACILITY TO GENERATOR <br />�� i <br />