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Y Please print or type. (Forth designed for use on elileoilch) typewriter.) <br />• <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. G EBd E R ATO R'S INITIAL COPY <br />1 Generator ID umber <br />UNIFORM HAZARDOUSN <br />. <br />2Page 1 of <br />. <br />3Grmagnncy Rnslanise Phueo <br />ackinng Number <br />4. Manifest Tracking <br />WASTE MANIFEST <br />`� � 4fl' P M W <br />s1 <br />y <br />n <br />5. Geeralor's Name and Mailing Address Geneml.,'s Site Address (if dilferanr than mailing address) <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />11 ..' ,r . 1, <br />pry i <br />7. Transporter Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Lr�AA"1yHl(Ffl'NI {� � _ <br />Facilltys Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Heard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group it any)) <br />Quantity <br />WI.NaI. <br />13. Waste Codes <br />No. <br />Type <br />1' 001 w --u fa+' b,°2; i tAla`:Aftt+!'rat•, WA,.jYt <a; <br />a <br />w <br />z <br />2. <br />w <br />t, <br />3. <br />4. <br />14.S pecial Handling InsWctlonsand Atldih'onal Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described shove by the proper shipping name, and am classified, packaged, <br />marked and IabeleNplararded, 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 witty that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (t I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatofs/Oterafs Pdnted7Typed Name Signature <br />Month Day Year <br />16. International Shipments ❑ <br />Import to U.S. ❑ Export from U.S. Pon <br />r of entry/exit: <br />= Transporter signature (for exports only): Dale leaving U.S.: <br />w 17. TransporterAckwatedgment of Receipt of Materials <br />Transporter 1 Printed7Typed Name Signature ' " �.—^ <br />-' <br />Month Day Year <br />O <br />ipw <br />G Transporter 2 PrintedlTyped Name Signature <br />Month Day Year <br />tr <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Ouantly 1:1 Type E] Residue <br />❑Partial Rejection <br />11 Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) <br />Monty Day Year <br />a <br />Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />t0. <br />23. <br />wner Designated Facility oor Operator. Certification of receipt of ha�rdwis materials covered by the manifest except as noted in Item 18ated7Typed <br />Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. G EBd E R ATO R'S INITIAL COPY <br />