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09/18/2013 14:56 120933n1873 FLAGCITV CHEVR PAGE 09109 <br />% <br />Please print or typo, (Form desioned for use on elile MMitch) tvnewriMr.) <br />Gnrm AnnrnvMl rtARR Mn 'Mrn.nnao <br />FPA Form 8700-22 (R V�5) Previous editlons are obartlete. *11'.. r" ' fl DESIGNATED FACILITY TO GENERATOR <br />UMFORM HAZARDOUS <br />1, GPneratrx 1D Number 2, Pap t of 3. Emergency %p Tnso Phone <br />kl�np�Nlnnlmr <br />4. Mansoet Trae0017382.75 <br />WASTE MANIFEST <br />r e; ' I 204-067^ 7 <br />l <br />f +:� L,. <br />5 GCnaralCr'G Name an(I MAIM AddrosSGeneretork S1to Addron (lf 019t ronl than marpng addrese) <br />{ <br />F 7AA y Ar,Uy/ <br />H. 'fres 1 G:o N ma U.S, E A ip Number <br />�r#� if a �+R NF1" WASTE lid CAL.O30f 27878 <br />7, TranCphrter 2.Company Nat11e . U.S, EPA IG Number <br />U.S. EPA ID Number <br />53M +C:UI1M ROAD <br />RR1/ERBANKN SCA 9,5307 2094M-6181 <br />Fadlity's Phone: <br />ga <br />9b. U.S. DCT Gescrtptlon (including Proper Shipping Narrat, Hjuarcl Class, ID Numtbor, <br />10. Contalnera11. <br />Total <br />12. Unit <br />13. Warot; <br />ta God <br />No. <br />Tyco <br />HM <br />end Packing Group (If any)) <br />fluarlifty <br />wt,Nnl, <br />a <br />1.14014MCKA MAWR]$ WA'STE MAU10 <br />221 <br />� <br />W <br />M <br />2, <br />W <br />4, <br />14.9pedal HandRn tIDtrRjd Additional Informallon <br />15, 908RATOR'3IOFFEROR'S CERTIFICATION: I hereby declare thet ft contents of arts consignment aro fully and ocournielydemribed Move by the proper ahlpplog name, ontl aro cieaelfiad, packaged, <br />marked and labeledtplacarded, and are in all reapert9 kr ptorm oondlilnn for trataporl aCWHIng to rgtplkxrble international and national govammcma l fe"l(pne, 0 eXport 91dDM and I am the Primary <br />Exporter, I CrttHy Ihot thin cmltMO: of ibis cnnsignmrmi conform to rho Wftj of the snached EPAAdmowledhrttant of C4rmoni, <br />I corlify thot Inc waslo ininirrizatlon statement Idonlitied In 40 CFR 262,27(x) Cif I om' a largo quantity gw.raiw) or {b) (If I am a small querdlly ganorator) Is Irua <br />neramr'e eror's PrintedlTypW Nartre gna urg oat ra <br />-1 <br />F <br />IH.1ntcrmllnnni ShipmP-nls <br />❑ import toU.S. ❑Export frwnU,S, Pon ofonlrylcrxik—._--.----.—.--_--- <br />Trans over signature for exports only): We leaving U.S,! <br />UJI <br />17, Transporter Acknowledgment of Rarolpt of Materlal„ <br />TwVDrtar 1 PrinledfTypodName gnarirm onEr ay oar <br />EL <br />Y <br />~ <br />Trarparwr 2 PrintodlTypod Namo' Sigrntture �,^.T^' Monts Day Year <br />a <br />F- <br />16. Dlacrepancy <br />f� I7-11 <br />Nye. Disernptrxq Indication Speco ❑ Ck.,antity ❑ Typo 1Realdue ❑ Partial Rokxtion ❑ Ftlfl Releotbn <br />WON Rete ce Number <br />91), Alternate Facility (Cr Genoralor) U.S. ERk1D Number <br />U <br />Facfli 'G Phone <br />Fd - <br />Ift. 31gnature ofAltemate Facility (or Genorntor) Month Day Year <br />a <br />1A Hazardous Waste Report Mnnagrmnnl Moutnd Code, (1,ra„ nodes for hazardous wnom irfintment, Mpoaaf, and recycling system) <br />L <br />In <br />Pry - <br />2. <br />20. Deslgrieted Facility Owner or Opemtor. Cartdicatlon of recglpt c hmzartlous matP..rlals covered by tho manifest Wept as no od Irl Item 16a ) <br />(JQr.IfTypcdNrmte j SgC I{e J Month Day Year <br />FPA Form 8700-22 (R V�5) Previous editlons are obartlete. *11'.. r" ' fl DESIGNATED FACILITY TO GENERATOR <br />