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OL <br />Please print or lupe. (Forth designed for use on elite (12 -pitch) tvwwriter.) <br />OL- 3 Form AwioveSCA&UU:! <br />EPA Form 8700-22 (Rev. 3415) Previous edition's are obsolete. .0or Id-NATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />(�(� ��� LL <br />2. Page 1 of <br />3. Emergency {R/esponse Phone <br />�v ^'/� 3% 8 <br />4. Manffest Tracking Number ee <br />0 0 9 6 2 7 3 0 FLE <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />S' <br />+r <br />yr <br />Generators Phone: di ^ 32 3 7-3 <br />ransporter Y erne U.S. EPA ID Number <br />< JF Uv) tV-J tet,-Ars.L nn. A 0 63 13 as Is- C5 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Pacility Name and Site Address U.S. EPA ID Number <br />Q q Kr+s 9"W'-- Chs V-cr <br />b2.o �sI C�t�..c Sc c._a-.C- ��V1cs .mks gyp►- C1333ti'1 <br />C A L' 01C) �3 s'�, <br />Facility's Phone: <br />ga, <br />9b. U.S. DDT Description ('including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group ff any)) <br />Quantity <br />Wtivol. <br />0 <br />1 N or.�a- }l i�Z`�S �..) oa�t1, <br />pc7l <br />3911 <br />LU <br />W <br />2. <br />r;9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlen of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition or transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I cer8fy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />s! Printed/Typed Name Signature • ay Year <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U rt of entryle dt <br />Transporter signature for exports on : Data leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />T 1 Pr n ypecl month Day Year <br />ZQ <br />Transporter 2 Printed/Typed Name Signature Month ay year <br />i <br />18. Discrepancy <br />,/ <br />18a. Discrepancy Indication Space 5 �andty ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />1 <br />r <br />S Manifest Reference Number: <br />1Bb. Alternate Facility ( neratm) U.S. EPA ID Number <br />U <br />Q <br />r+- <br />Faafi s Phone: <br />18c. Signature of Attemate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Cafes (i.e., axles for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1.2. <br />alql <br />1 <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Cerfifiption of receipt of hazardous materials covered by the manifest except as noted in item 18a <br />Printed/Typed Name Signatu Month Day Year <br />Ito O 1 <br />EPA Form 8700-22 (Rev. 3415) Previous edition's are obsolete. .0or Id-NATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />