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<br />I 11111 II Ill II
<br /> GENERATOR UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />I GenPV'l ID '4 ''tt''
<br />I I 1 .i. tO.... I o. , 015096253 FLE
<br />'. Generator's Name and Mating Addies, 1- I 10 7 !'. I t r I I : 4 4'. t ' • 11 '4 I I 4 ()I I CA.-e.rx._, 1 Sae Alive i i r diserwe ran 47'.1...,,g 3C1.2.M13.
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<br />t, ii .., i • •,t,,, 1 Company Name US EPA ID Minter
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<br />liaTISpillef 2 Company Nellie US EPA ID Number
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<br />:.• 1'V:quiet' Facihry Name and SlIttAddiess ,, 1 ... I r ' (1 i I r, r y 1. 10.1 I 1 I US EPA ID Number
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<br />n.i 9( US DOT Deurphon (including Proper Stuppng Name, Hazard Class. ID Number 10 Contaners II Total 12 Und 13 Wastn Codes ..•,. and Packing Group tit any)) No - tyf....., Duane(' VA Nol
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<br />14 Special Handling Instructions and Addibonal Informaton I. 1 I 1 t4t1 ( N a 1.11re 1 PIO F 11 1.1 11411 0 F. f : ) . , c o- I . (+fen l ight
<br />i libei 8 131.e1bs) 3.109743 (1- tameable 8o1 id Loq5/43.21:1() 4. 10.)/137 .1., •-• I. lc I:14e l.iyuLds l.noeparV
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<br />15 GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of trio consignment are fully and accurately descrted above by the proper shipping name. aid are classified. packaged.
<br />marked and labeledlpfacarded. and a7e in all respects in proper condition for transport according to applicable rtemaeonaland national governmental regulations If export sh.pment and I am the Pnmary
<br />Exporter. I certify that the contents of this consignment conform To the terms of the attached EPA Acknowledgment of Consent
<br />I certify that the waste trIIMMIZatIOn statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (ill am a smad quantity generator) is true
<br />GeneraiorOfferors Printect,Typed Namet Signature 1.._ 1 P.Ionth Day Year
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<br />18 -Int bonal Shipments Import to US II Export from US PIS \ / —
<br />Transporter signature (for exports only) Date leaving US . Z\ TRANSPORTER Transporter Acknowiedgment of Recept of Materials i' )
<br />Transporter 1 PnntediTyped Name Signature .2 Montn Day Y...;,'
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<br />Transporter 2 PnntedlTyped Name (-Signature Month Day jrYe
<br />I I I I I DESIGNATED FACILITY Discrepancy
<br />I8a Discrepancy Indicabon Space El Quantity Ill Type Residue Partial Refection Full Rejection
<br />Manifest Reference Number
<br />18b Alternate Facility for Generator) US EPA ID Number
<br />Facildfs Phone I
<br />Iac Signature of Alternate Faolay (or Generator) f.lanth Da; Yey
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<br />19 1-ia:a.,1z.:1.1.,:,51e Report Management Method Codes (c e .codes for hazardous waste treatment, dsposal, and recycling systems)
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<br />20 Designated Fact.ty (Tyner or Operator Ceraficaton of receipt of hazardous matenals covered by the man.fest except as tided in Item 183
<br />Printed'Typed Name Signature I.lontn 0..1/
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<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete
<br /> GENERATOR'S MAL COPY
<br />1(4111-i-Y _1 ?v3 CK71-.19.24 c al I 01(,51)L4 0419518311 14
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