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Please orint or lime. (Form destined for use on elite (12-Dflch) Imewriter)
<br />Form Approved. OMB No. 2050-01139
<br />EPAForm8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
<br />UNIFORM HAZARDOUS 1. Generator,1) Number
<br />UNIFORM
<br />2. Page1W
<br />3Emergmwy Resporoe Phone
<br />.Menifeat Trecking Number,
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<br />000145 110 DAT
<br />5 Generator's Name and Mailing Address ''' Ga tars SbAddrmptdge [Umnmaiingaddress)
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<br />Generators Phone 5+(I(!(f £!?1! ii trot{'i, tiN }c;(F'fliU f'fa+{t IQ 3U ruts vi iA1 i. ge f'+",11 '011:if L�16
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<br />6. Transporter i Company Name - ... _. ...' ..': ... U.S, FPA D Number
<br />tbi'l+.iilf.d7 IX151)i 5101Al0.005- 4:N11
<br />7. Transporter 2 Company Name •:.. .. ,.. - US. EPA ID Number.
<br />SD Ignared Faeify Nameand SileAddress ., , , .. ... U.S. EPA D Number
<br />iR, 10,1 d'tb
<br />FMtit sPhone.+)1t+moi WW '; s,.i �`.fi!iOr s{1110- _ i+i`Yr.i7°3i'?{kY6 t'I :ief
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<br />Sb. U.S. 00T Description (induding Proper Shipping Name, Hazard Class, ID Numbet - .
<br />10. Centel"
<br />11. Total
<br />12. Ung
<br />13. Waste Codes
<br />.No.
<br />Type.::
<br />Wand
<br />Padtlng Group(dany))
<br />Quantity
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<br />Will
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<br />14 SpeclaIM ing maVudion;mw ddltlund lt7apmtlan -
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<br />15 GENERATOR'SDFFERORS CERTIFICATION: IImrebydedme, lhatme contacts of this coaslgnmantamfuly and accurately descrbelAboym by Ste propershlpporg name, ardam;Imp Sed,jaw4med,
<br />marked and labeledldawrded and are N al respells In proper oandthon for transport according to applicaY a mterrationaland national governmental regulations. 9 ezpodsNpnteet and in the Pdmary
<br />Expo r:l ceriifygmtthe contents of this ooneignmenlcadmm to the terms of We aSeched EPAAcknovA ment of Consent -'
<br />I certi Smlthe waste rtmlmba0an slatemeM ldentlfled N40 CFR 26227(e)(thlemalerge quenllty genera r) or(E)gtl am a sm I gmNSygenerator) Is We.
<br />Garomforst re Pdnfed.W dila - -' Sign Month ";Do Year
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<br />16. bdernaton IShipments -r
<br />❑Import to U.S. ❑Exportfrom U.S. Pad ofanhyedL
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<br />Transporter nalura(for exports only): Date leaving U.S.:
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<br />`17,Trens(WrAcknowledgmenh of Receipt of Materiels `
<br />Tranapodm i Pdn1,90 ped Name SltinsOae -.. , Month Day Your
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<br />Trans erg Pd7 dName SIgh ure Month DayYear,.
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<br />18. Discrepancy
<br />188. Discrepancy Weston Space ❑ Quantity ❑ Type ❑ Residue El Partial Refection ❑ Full Re)edron
<br />Manifest Reference Number:
<br />18b.Altemale.FaIlKy(arGennierf, US. EPAD Number
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<br />Fool Phone: .:r.
<br />I& Signatum of Alternate Facility(or Generator) - - -
<br />MonthDay Year
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<br />m19.
<br />Hazanous Waste Report Management Method Codes (ie.,oades for hazardous waste treatment dsposal, and recycling systema)
<br />20. Desbnated Facility Owner or Operator. Certification of receiplof hazardous materials cowered by the manlfeat exceptas Med N thorn 18a
<br />Pdntedrryped Name Spnatum Month Day Year
<br />EPAForm8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
<br />
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