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Please print or tope. (Form designed for use on elite f12-oitch) Ivr iIn0 <br />C— e—,, —4 !LAO kl.. anan 0:i' - <br />EPA Form 8700.22 01v 3-05) Previius editions are obsolete <br />DE- ,NATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />'UNIFORM HAZARDOUS <br />1, Generator ID NumberJ <br />2. Page 1 of <br />3. Emergency Response Phone <br />4, Manifest Tracking Number <br />WASTE MANIFEST <br />C <br />1 GAL000 a � ! <br />a00 L,tI-9300 <br />o 7617001 <br />JJK <br />5. Generator's Name and Address f,_ fs 1_ Generators Site Address (if differenl than mailing address) <br />1Mailing <br />ee <br />/S`YS3 (f40^fO+V i0,4.4 f/�,� <br />1 oc� l I e—A. <br />Generators Phone: <br />B. Transporter 1 Company Name <br />U.S. EPA ID Number <br />r—AgOoD17101 7 <br />7. Transporter 2 Company Name <br />U S. EPA ID Number <br />8. Designated Facility Name and Site Address T T i O A.) <br />J <br />U.S. EPA ID Number <br />%ion C.1�rV/'0pv wt,nJr7 <br />�hJIAo , !✓'�io <br />Fadi s plwn <br />d ZL6 <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 />13 Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (1 any)) <br />Quany <br />bNol. <br />W2 <br />° <br />,.1.x S el, r'Jur� <br />o, <br />z <br />2. <br />c� <br />3. <br />4. <br />14. Special Handling Inslnicl ons and Additional Information a / /� kmay{ 1 / t� <br />\ <br />15. GEN ERATOR'Sl0 FEROR'S CERTIFICATION: I hereby dedare that the content of this consignment are fully and accurately described above by the proper sh'ppiag name, and are classified, <br />packaged, <br />marked and labeled/placarded, and are In all respects in proper condition for transport according to app9cabia intemal onat and naGenal governmental regulations. If export shipment and I am the Primary <br />Exporter, I cartily that the contents of this consignment conform to the terms of the arached EPA Acknowledgment of Consent. <br />1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if . am a large quantity generator) or tq.l am a small est <br />nerator) is We. <br />eneratceslOffercrs PnintedIrCd Ne signature <br />Month <br />Day Year <br />r <br />o�IS <br />I ' a <br />ZJ <br />16 Internat onal Shil ❑ Export from U S Port c I !ext: <br />11 Import to U S. pc ry <br />Transporter signature (for exports only;: la leaving U.S.: <br />Ce <br />17 Transporter Acknowledgment Receipt of Materials <br />� <br />7 fell Prntedffyped a Sg tun <br />Month <br />Da= Year <br />O <br />IL <br />1. L <br />I ryd I <br />Ly <br />2 <br />4 <br />Transporter 2 Pnnte ypedNama Sgnature <br />Month <br />Day Year <br />a <br />18. Discrepancy <br />18a. Discrepancy mdiast o Space <br />ElQuantity Type Residue <br />❑ Partial Rejection Full Rejection <br />Manifest Reference Number <br />18b Alternate Facil,ly for Gencaah i <br />U S. EPA 10 Number <br />L) <br />LL <br />Facllitys Phone <br />W <br />18c. Signature of Aliemate Facility (or Generator) <br />Month <br />Day Year <br />Q <br />Z <br />19 Hazardous Waste Report Management Method Codes ( 9, codes for hazardous waste treatment, disposal and recycling systems) <br />0 <br />1. <br />2. <br />3 <br />4. <br />0 Designated Fact ty Owner cr Oporator Cen ficafion of receipt of hazardous maleriats covered by the manifest except as noted n tem 18a <br />Primeda ame Si re <br />Month <br />Day Yeara161 <br />r <br />& <br />EPA Form 8700.22 01v 3-05) Previius editions are obsolete <br />DE- ,NATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />