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i <br />' Please pnr6sr"Ie. trorm designed for use on elite (1 - Itchl rioewdter.l � __-_.._. ....,,✓...., <br />'c PA Form 700-22 (Rev. 3-05) Previous edilions are obsolete.. GENERATOR'S INITIA!_ I'n+7` <br />u nppmxw. vmo nu. cuou-UWV <br />UNIFORM HAZARDOUS 1•GenereMrlDNumber 2. Pagetof 3 Emergency Response Phone 4.klarift"t Tracking Number <br />- <br />WASTE MANIFEST S:AGtItNt2E5{Ys7 , "A r } .1.14 b3GO ""HE IVII A -C 0 D 9 2 JJ K <br />5. Generators Name and Mailing Address F'IS;KNFULL. lUti'U415R+V1pIi'L61t3 Generators SlteAddreas (if difereM than mailing address) <br />i n.ki�•,.,.e..;rNKnHt <br />10£50C;NJLOCHNTEROSIVA: 3 A j b 1 <br />:::.i �r�;., r•a <br />HAI`4040 G0Rtx1VA, (`.rA 'aSC 0 '. <br />Generators Phone`:' t rUr 73R <br />6. Transporter 1 Company Name 4 U.S. EPA ID Number <br />-.rci.:NW:.KfitSlF.'AN3RCDRIME'1'41 AI. F<EkVlt^. E'"+fhiC' i::{t::�.,::-1, :. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />.-a r'ti+i RlfdY i"t4VIR1;)IJkRFiN1A1. MAl+tiu,t'Mirs:. d ran S "lP-: ic. .. I {n -:1;,a,,; - <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />t3Y' [FSJN Ei••NIRQP�;lENt11S. C1{�fii�t ti'.:'.�Irih; <br />14'10 6 Ci A4VWT HtOioi) <br />F RE-DOIJI K; W, V,i <br />Facility's Phone:'S 1(5 4379 445 <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />f0. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />wt./Vol.13. <br />Waste Codes <br />No <br />Type <br />C <br />1. NJ 144l6. 11vA4el ' L$ewwwWa, UQtA% h4( ., ti"N'I ,:.1 ? .. <br />.LMA— <br />44.1 <br />lhu;1 <br />Z <br />2. <br />W <br />(9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />E kaY;t$fi4k to Ur. it! U:A1r1ant:1nr1 USse ppe; <br />V <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described some 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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27(x) (f I am a large quantity generator) or (b) If I am a small quantity generator) is true. <br />G4neretors/Oferors Pdntedlryped Name Signature Month Day Year <br />-+ <br />z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port " <br />of entylexa: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Recelpt of Materials <br />0 <br />Trensporter 1 hmmadoyped Name Signature Month Day Year <br />QK <br />Trans der2 Prince r e <br />po d/Typd Name Signature <br />Month -Day Year <br />jis <br />Discrepancy <br />18a. Discrepancy Indication Space ❑ Quen' <br />mY ❑ TyDe El Residue ❑ ParBal Rejection El Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generates)U.S. <br />EPA 10 Number <br />U <br />W <br />Facilitys Phone: <br />18c. Signature ofAltemate Facility(or Genendor) <br />Q <br />Month Day Year <br />2 <br />W19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1: 2.- <br />.20. <br />20.Designated Facility Owner or Operator: Certification of receipt dhazardous materials coveriid by the manifest except as noted in Item Ise <br />I <br />Pdnledrryped Name Signature Month Day Year <br />'c PA Form 700-22 (Rev. 3-05) Previous edilions are obsolete.. GENERATOR'S INITIA!_ I'n+7` <br />