Laserfiche WebLink
0 <br />Please print or type. (Form designed forum on elite (12 -pitch) typewriter.) <br />E <br />Form Aooroved. OMR No. 2050.0039 <br />EPA Forth 8700.22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />Generator ID Number <br />12.Pagelof <br />3 Emergolwy Response Phone <br />4. Maanflest racNumber <br />WASMANIFEST <br />014795178 <br />QatJam�tofs Name and Mailing Addresst Gene,afor's Site Address (it atheism than mailing address) <br />..;5. <br />Yj R. L. iAYM z Cr,O FiSCita- j'£ dJY {• y:. '.. <br />L.- .L.r..54' 4 a/F to •{.x::: <br />Gwwrdto?s.r.,- <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transponar2 Company Name <br />U.S. EFA IU Number <br />8. Designated Facllk Name and Site Address <br />US. EPA ID Number <br />FacitVs Phone: <br />9, <br />9b. U.S. DOT Descdptia, (including Proper Shipping Name, Hazarc Class, ID Number <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />Mr. <br />Type <br />HM <br />Mrd Pawng Group of any) <br />Quantity <br />Wt.Not. <br />Q <br />I ... <br />"' <br />RC <br />3. <br />4. <br />14 Special Handling InstructorsandAdd!J II f nation <br />t ., <br />1 <br />i <br />15 GENERATOR'SADFFEROR'S CERTIFICATION: I hereoy declare that the centenis of this consignment am fully and socurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are In aE respects in proper Condition for transport according to applicable International and national governmental <br />regulations. If export shipmentand <br />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 canny that the waste minimization statement identified in 40 CFR 262.27(a) (NI am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatotst0flerol's PrintedfTyped Name Signature <br />Month Day Year <br />_+ <br />16. International StIpmena <br />E-1 Import to U.S. El Export from U.S Port of entry/exit:.__, <br />= <br />Transporter signature(for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials ,�.. <br />Transporw 1 Printedlftped Name SOwre <br />Month Day Yeer <br />L ��3 ; 'gip tN 1sIII, A <br />VQ Ilk <br />4 <br />Transporter 2 Print Typed NamSignature <br />Month Day Year <br />18. Or <br />18a, Discrepancy Indication Space ❑Quantity UTyPe ❑Residus <br />❑ Partial Re)aedOn <br />❑Full Rejector. <br />Manifest Reference Number: <br />18b, Alternate Facility (or Generated <br />U.S. EPA ID Number <br />J <br />rdi <br />FacIVs Phone: <br />1&;. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Repot Management Me" Codes {i.e., codes tot hazarcous waste treatment, disposal, and recycling systems) <br />bar <br />)� <br />2. 3. <br />4. <br />20 Designated Facility Owner or Operator CwHissdon of receipt of hazardous materiels Covered by the manifest except as noted in Item l8a <br />PrIntecirrypedNears Signature r <br />" <br />Month^ Day Year <br />EPA Forth 8700.22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />