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Please print or tyle. (Form designed for use on elite (12 -pitch) tvpewdter.) <br />Form ADDroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />1 Ge erator ID Number., <br />UNIFORM HAZARDOUS i <br />2. Page 1 of <br />3. Emergency Response Phone <br />451b <br />4. Manifest Tracking Number <br />101245,9760 <br />WASTE MANIFEST Y i1 5' 1 �{ <br />JJ <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />I:x�a <br />Generators Phone: <br />6 Transporter 1 CompanyName U.S. EPA ID Number <br />t <br />(:= ..'s4,.J ',A "..O ;+O t1 tt ,t r'.:.I (':�( .w"% !. "� t.i '-) _ `' Q 9 15 t 0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. DesjgrietadfatiHty4,4eq a and Site Address U.S. EPA ID Number <br />mt <br />Facility's Phone: <br />ga, <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 (if any)) <br />Quantity <br />Wt.Nol. <br />1 rPlfit <br />f._� <br />O <br />Z <br />k.a �: - t'.7. 'M"( !yP i. + �',+'3 aC <br />2: .. i`, W.j+.i! [+ :4 3. <br />!f' <br />A'.ii <br />! ' .�,... <br />OWN <br />f...E�{t� <br />� <br />+ ,.. <br />� rt1 +.. y+'I? +kIP'i;. s+ra.�r,+��+r , I..iiii�i8, f#, f'��IMR <br />'3 Ad ('='+rttt -41% JF <br />43 1 l4 1'114..>t A t i.i1.i;�' ai`; .*. t <br />,ae <br />14. Special Handling Instructions and Additional Information 1)(I I 111111, M. 3) i,t I l:' I Ubg:`' 1 I . "+,:; { ; I, I r 1 11i100]; -3 t) 7f)1: ' i"7-653a� .. ' 7 <br />t,,!' I•�i+f`'3bitlttttt?t11+1(?11iI iiet'f7fr e?i�ik)1v1d1xlFl" ifb$14t"iit%�.{IfE1'i iJP, �? <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I 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) ('d I am a large quantity generator) or (b) (;I am a small quantity generator) is true. <br />✓ -" <br />Generators/OfferorsPrinted/T NameSignature Month Day Year., <br />� � t • <br />P l ly ` f <br />P- <br />16. International Shipments-.. N <br />E]Import to U.S. ❑ Export from,U:S. Port of entry/exit <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LCC <br />17. Transporter Acknowledgment of Receipt of Materials <br />TransporterlPrintetd/Typed Name Signature MonthDay Year,. <br />O <br />, <br />r + <br />t ' <br />Z <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />J <br />x— <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity El Type El Residue El Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />U- <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q1Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />