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Please Drint or tvoe. (Form designed Mrimp nn autw 1119. 4'h1 s„��..ao� ”' <br />Day Year <br />i <br />EPA Form 8700-22 (Rev. 3-05) Previous edltions are obsolete.. DESINATEI� FACILITY'S COPY <br />SF�`1 <br />I , <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3 Emergency Response Phone <br />4 Manifest Tracking Number <br />WASTE MANIFEST <br />C ,i6t; 5r 0 0 . Y 0 ,1 1 f:1 .? ... <br />4r'j� �„:tl � <br />i„� 1 <br />1 <br />JJ <br />5. Gen ergdtors Niiamea d Maid Address Generator's Site Address (if different than mailing address) <br />13Ry�•W/SINSTy NCAINS <br />��g� <br />a 0 1S�.f,Jf'1 'iC7'l. i�",Y' *0A <br />Generator's Phone:`- <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />k�'•°k�3'r1, ` c"E'i��s <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />6. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />C .tit 4- . _3 ,t <br />Facility's Phone: .: <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />1t: Total <br />12, Unit <br />HM <br />and Packing Group (f any)) <br />'Quantity <br />Wt.m. <br />13. Waste <br />Codes <br />No. <br />Type <br />I. <br />� <br />iAO4y 'OUS WASTE,1 D 0f 4 WA11:-.5 <br />r., <br />Y f`r'e <br />�`'��•'Y +a <br />11 <br />Z <br />� <br />2. <br />LLJ <br />3. <br />4. <br />I <br />14. Special Handling Instructions and Additional Information <br />.RSed3&F1-101F07 WE EQiN T <br />W- R.or`i98d }-3O3RIAT-FE. R <br />15. GENERATOR'S/OFF'EROR'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 labeled/placarded, and are in aN 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 />I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large qudnq,l g nerator) or (b) (if I am a small quantity generator) is true. <br />d <br />Generators/Offewors.PiintedlTped Nameoignature <br />Month <br />Day Year <br />ev <br />If <br />J <br />H <br />16. International Shipments - . <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. TransporterAdmowledgpnt of Receipt of Materials F <br />r <br />Transpo�lef” Pygrinted/T pgtl Name Signatu e” {r Month)C <br />+ rr. <br />"•`1+ <br />Day Ye}ar <br />�. <br />a. <br />ii?�•us:uiy,)r,-r'fL./ <br />•i <br />dw{ ��•. N k'•r�1kpy; <br />DL, <br />4Month <br />Transporter 2Printed/TypedName ,�� Signaturf <br />Day Year <br />r- <br />18. Discrepancy <br />1 Be. Discrepancy Indication Space ❑ Quantity El Type ❑Residue <br />❑Partial Rejection ❑Full <br />Rejection <br />Manifest Reference Number: <br />18b. Allemate Facility (or Generator) <br />U.S. EPA ID Number <br />J_ <br />V <br />Facilitys Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month <br />Day Year <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C3 <br />1. y s'_ <br />2. <br />3. <br />4, <br />20. Designated Facility Owner or Operator: Certification of rerx3lpt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name pr i t- Signature <br />3 At60 <br />Day Year <br />i <br />EPA Form 8700-22 (Rev. 3-05) Previous edltions are obsolete.. DESINATEI� FACILITY'S COPY <br />SF�`1 <br />I , <br />