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Please print or type. (Form designed for use on elite (12 -pitch) typewriter. <br />Form An roved OMB No 2050-0039 <br />EPA Form 8700-22(Rev°3.05) Previous edltlbns are obsolete. DESI1r3NATED FACILITY TO GENERATOR STATE (IF REOUIRED) <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number <br />2. Page 1 of3. <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />;p. t;t <br />la ;. () 0 0 1 .1 §,3 3 2 <br />1 <br />r800):0) 424-: 300 <br />v <br />-5-19, 2' U JJ K <br />5. Genera o�s��tame Malling Address ? Generator's Site Address (if different than mailing address) <br />1111301 Nt4N ST 1130 N ST <br />�N`p <br />Generatols Phone: 1, CS t ' 05gs 5 <br />6. Trans,porter1 Company Name U.S. EPA ID Number <br />A4eUR E1AuC)V@—ENsiL hEP,\fK,,ET C A TJ V` 2 N 2' g d'' 0 -3 t <br />7• Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA 10 Number <br />NVS ENVIRONWNT& SERVICES <br />'11~9$-5 SOUTH RIVER ROADWESTSAICRAONTO <br />y, <br />Facility's Phone: i 0 41r . $ 0 1 4 it 0 a 5 5 °r',, <br />ga, <br />9b, U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (ff any)) <br />Quantity <br />Wt.Nol, <br />re <br />1 <br />0 <br />ICON-RCRA t -11A ARDOUS WASTE, LIQUID (=". ILY WATER) <br />Ci RSH ,rpp 1.. <br />ry #,a T <br />t� <br />C.3i• <br />t <br />2 <br />2. <br />W <br />0 <br />3. <br />4. <br />14. Special Handing Instructions and Additional Information <br />int; liWo g : i71xpt1i -r 08 ) '70W,5,09 ,r ADDITIONAL rrPXOC)S ;i1 NONE 'APPIO-PRIATE, iii)(. <br />#aRO TEACMAE tOUI ifs, NT ` <br />15. GENERATOR'SfOFFEROR'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 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. » a <br />1 <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quanIlly enerator) or (b) (if I erp a small quarifity,,genpretor) is true. <br />aneLr <br />az tors]Offer(0 Prinonp th Day <br />nPe <br />1,�S.gt°at4w" <br />Ms,p <br />J 3Year <br />.+' <br />e • <br />j <br />16.IntenatlohalShipments Import to U"S". Export from U.S. <br />? Port of efit exit: <br />_. <br />""" <br />Transporter signature (for exports only): Dale leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />I.- <br />Trensporter 1 PYotbdrryped Name c Signature a /,j Month Day Year <br />~ <br />CL <br />5 D • _ <br />= ,isF,,.. T r.'t[ F �t n <br />v . GY. y &$I r. <br />s} —,M`n �fr; <br />Z <br />Transporter 2 Printedfryped Nam6Signature r' ! Month Day Year <br />18. Discrepancy <br />1Ba. Discrepancy Indication Space ❑ Quant( ❑ e ❑ Residue <br />ry Typ ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />LL <br />FacilitysPhone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />20. Designaled Facility Amer or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pdnted/Typed Name Si itmonthMonth Day Year <br />] <br />EPA Form 8700-22(Rev°3.05) Previous edltlbns are obsolete. DESI1r3NATED FACILITY TO GENERATOR STATE (IF REOUIRED) <br />