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Please pdrit or type. (Forth designed for use on elite (12-pttypevrtitec) <br />• Fn,m Ann —A nuo3n <br />GENERATOR'S INITIAL COP'S' <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phose <br />4. Manifest <br />Tracking Number V� V .0�Vw <br />WASTE MANIFEST0 'A <br />x'� <br />F ii 5 ��v <br />_u+ <br />9 i <br />5. Generators NS' ha and Mailing Address Generators Site Address (if different than mailing address) <br />a. <br />Generators Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />'-x,.i FAnrd-ay 4S4:.i Yimw9i»ox <br />-, 5t <br />8. Designated Fadlity Name and Site Address <br />_ x, :,,7 -,V, U.S. EPA ID Number <br />17`A,--V—r iM1 b'.r <br />°+q4 Aro 9yi5 <br />Facility's Phone. `12T1-7a.!--.wv!f; <br />ga. <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contairceas <br />11. Total <br />12. Ung <br />12.1 <br />HM <br />and Packing Group (if any)) <br />Quantity <br />13. Waste Codes <br />No. <br />Type <br />1.= .v M4�ktA iimear+#xwK We9in zrsA td tb.hly <br />C <br />;', ,}• <br />C <br />/0. <br />}s <br />w <br />� <br />2. <br />w <br />0 <br />3. <br />4. <br />14, Special Handling Instructions and Additional Information <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 Iabeledlplacarded, 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 coldly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I celdfy that the waste minimization statement identified in 40 CFR 261 (8I am a large quantity genemtor) or (bj (81 am a small quantity generator) is true. <br />Gen4retor fieri PrintedRypa ame Signature r'.I Month Day. Year <br />01 L <br />, . <br />16. International Shipments <br />❑Import to U.S. Ll Expand from U.S. Port <br />of entrymetit: <br />Transporter signature (for exports only): Dale leaving U.S.: <br />w <br />17, Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pdntedrryped Name . <br />Slgnelure_ <br />O <br />rj - ��._ Month Day Year <br />za <br />Tmnsponer 2 PnntedRyped Name Signature <br />a <br />Month Day Year <br />F <br />♦ <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouantity, ❑7 Ype El Residue ❑Partial Rejection ❑Full <br />Rejection <br />IZ <br />18h. Alternate FacilityManifest Reference Number: (or Generator) <br />7 <br />U.S. EPA ID Number <br />V <br />ram <br />Facilitys Phone: <br />w <br />1K Signature OrAltemate Fadlity(or Generator) <br />4 <br />Month Day Year <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1 2. 3, <br />4. <br />20. Designated Facility Owner or Operator: Certification of recelpt of hazardous materials coveredly the manifest except as noted in Item i8a <br />Printed/typed Name Signature <br />Month Day Year <br />EPA <br />Form 8700-22 fRev. 3-051 Previnma Orli inns are nhi, mli <br />GENERATOR'S INITIAL COP'S' <br />