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P69a onot or tvoe. (Form desioned for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No, 2050-4039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />V <br />Genera ID Number <br />2. Page 1 of <br />3. Emergent/Response Phone <br />Q. fllanifest TrackinNurpbe( , _. <br />UNIFORM HAZARDOUS <br />114 <br />� FLE <br />u x $ <br />WASTE MANIFEST <br />r', �; > <br />17 Ek > ..t "1 <br />- <br />�a r-:;;S`;.—�� r <br />kef '.ti F� �4• .s.r <br />i Fi t t65'f <br />, ,,-,•- <br />S. Generators Name and Mailing Address Goneraters Site Address (ff di fe'r[i'htthan mailing address) <br />A1is4��I Con <br />GenoratorsPhone; ;yz3.. ; [re u <br />6. Transporter 1 Company t ame ' - U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S, EPA ID Number <br />iV <br />l'..: i$ny—t�ys. #.mo <br />Facilihi's Phone: <br />Sa, <br />9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11, Total <br />12, Unit <br />13, Waste Codes <br />HM <br />and Packing Group (if any)) <br />No. <br />Type <br />Quantity <br />WtWal. <br />j y <br />�'-O cinf �A 1!�:i�u-"+i Teti�:''.�^� a`1.�'.Yairi <br />Z <br />2.LU <br />1 <br />ED. <br />....... <br />__......_ <br />3. <br />I <br />4. <br />i <br />a[ <br />F <br />14, 5psdal Handling Instructions and Additional Information <br />RtC Wit.` ${tsvt ';' tide.:% r �rpr' ri ? <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 proper condition for transport according to applicable International and 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 EPAAcknowledgment of Consent, <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity genp(ator) is iruo, <br />eneralor'sr0lferofs PrmtedfTypLd Name Signature Month Day Tear <br />-J <br />1e, International Shipments <br />from Port <br />Import to U.S. L 1 Export U,S. of onlrylexit: _..._ P ....__...__-.....__....___._._...rm_......._._.. _ <br />z <br />Transporter signature (for exports only): Date leaving U:S,: <br />17. Transporter Acknowledgment of Receipt of Materials <br />a <br />Tr;7nsponer 1 Printed Typed Name 1 3 iggature ,pont ta ear <br />I <br />Cf <br />y{ <br />j <br />ua * z `tom Ji A<, r�.F#dz� <br />f <br />QTransporter <br />2 PdntedfTyped Name Signature Month Day Year <br />16. Discrepancy <br />tea. Disciepaiicy Indication Space quantity ❑Type ❑ Partial Rejection ® Full Rejection <br />Residue j <br />Manifest Reference Number: <br />I ft- Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />w <br />Fadlit s Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />4 <br />Z <br />N19, <br />Hazardous Waste Report Management Method Codes (i.e„ codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. v <br />2. <br />3. <br />A, <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in item tea <br />PrintedlTyped Name a �, Signature _ r Month Day Year <br />3 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />