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^r 1 <br />Plan— nrinf nr fvna fFnrm dasianed for use on elite (12-oltchl tvoewdter.) <br />Form Approved. OMB No. 2050-0039 <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2 Page 1 of <br />3. Emergency Response Phone <br />t t? b. g�,r ' <br />a''nIfest Tracking Number <br />4. M017145320 <br />1 1 4 5 32 0 JJR <br />WASTE MANIFEST <br />At �ii7tt3 °0` <br />1ra <br />V <br />5, Generators Name and Mailing Address Generator's Site Address (if different than malling address) <br />��RL�Tt�C>•r F,.=iER!r?t,= F+#�'GtJ�•'L "i t : 3r=,, ..,.r, f .; � -:; . . <br />i$q IA 1JS1'h'WL ! _ �;ti , <br />5T00<.T%4, Cry. X19 <br />Generators Pho T, -s 77 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />• <br />t`ei'�tO� EFf-"x1+. ...�di.•il, �" . ",CL,a B+jC. � IvJ�OLWJ{#1�t..t, <br />7. Transporter 2 Company Name U,S. EPA IDNumber <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />�':v3.drj.a� i':PhNN,ISt�r£?IHy:�.L 8Y'I?`-,?Cf?s utr1. r�rE;u�,u��mr�S <br />1515-Ca3CttR1,1?Pa0. <br />FaclLtys Phone'018-y'1- <br />ya <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10,.Contablers <br />14. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group Of any)) <br />Quantity <br />WtNol. <br />1. Nail PCRA, tYQAAMJ41 '104-9M4 ;SOLO to]., sWL Ftr lr <br />Wi <br />� <br />J <br />Z <br />x <br />LU <br />0 <br />3. <br />4. <br />%Special Handling Inshctions and Additional Information <br />L.s?. G1Ji�'iT'd_�.f,?ll?t'i; F►At�rfitr k�M.�i�.Jr'iif1~t4{7'a1. .,�" <br />1•L4401 EP 3 £t1E0= aLO TRAM °�E4 AM IJW APPR04P AF's. �' �" � <br />� 4 <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accuratelydescdbed above by the propershipping name, and are cleselfied, Paekagedk : )?: <br />marked and labeledlplacarded, 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 EPA Acknowledgment of Consent. <br />certify that the waste minimization statement Identified in 40 CFR Z62.27(a) Of I am a large quantity generator) or (b) (if I am a small quantity generator) Is he. <br />Generators/Offerors PrintedfTyped Name Signatmre Month DW YYiY' <br />T• - f ; <br />J' <br />F <br />18. itltamatlonal Shipments <br />, ❑ import to U.S. ❑ Export ft. U.S. Portof entryleAt <br />Z <br />. Transporter signature (for exports only): Date leaving U.S.: <br />a' <br />17. Transporter AcJmowiedgmentofReceipt ofMaterials <br />Transporter 1 Pdntedffypedt"am Sig tufa i Month Day Year <br />: <br />t i.. \ r1 71 <br />L <br />ca <br />Xminsporter 2 PrintedfTyped Name ature Month Day Year <br />16. Discrepancy <br />18a. Discrepancy Indication Space;• ., . <br />❑ Quantity ❑Type ❑ Residue ❑Partial Rejection ,�F.ttiRrj�Opo11' ; <br />Manifest Reference Number. <br />1 Bb. Alternate Factilty (or Generator) U.S. EPA ID Number <br />U <br />rai <br />Facltitys Ptane: <br />� <br />19c. SignaturedAltemate Facility (or Generator) Month Day : Y� <br />29 <br />19. Hazardous Waste Report ManagementMethod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. <br />q• <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manliest except as noted In Item 18a <br />Prinledfryped Name Signature Month Day Year <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />