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Please print or type. {Form dent iLd ful use on elite i 12-o:tch. -writer_y <br />Fnrm Annrnvwi nIVIR Nn 9n5n-nn3Q <br />EPA Form 8700-22 (Rav 3.05) Previous editions are oWleta. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1 Generator ID Number.T <br />2 Page t of <br />3 E ergency Respansa Phos <br />4. t n((�V�J�OUO-. <br />WASTE MANIFEST <br />A , 0 11 Li (11 1 1 it '1 1 <br />T <br />t;;jt1 4?¢ -:U00 <br />�� <br />Genera'ors Name and Mai'in Address Generators S'e Address (1 different than iiallmg address) <br />IR -Y i 94 <br />11301 N. MN ST 11-4i I'd 0MIq ST <br />M JWCA4� PI <br />A 16 WN CA W <br />Generators Phone z .i`�r, 4V-' <br />6 Transporter 1 Company Nance US EPA M Number <br />ASYMY F;1l1'IRON VEP4 [At. SER VICES C A D 0 9 2 t 7 n 3 6 <br />7 Transporter 2 Company Name U.S EPA ID Number <br />8 Gesignalod Facility Name and Sita Address U S. FPA ID Number <br />RAMS ENIARItlANTAL <br />16 If" C;("XJH{J-R ROAU <br />WESTvfWVKI LA :WN I C A D 0 4 4 0 j 3 5 a 6 <br />Fachit 's Phone 0 11 6113 11F741 <br />9a. <br />9b. U S DOT Deseniaton (indudiog Prupur Slipping Name, Hazard Class, ID Nranber, <br />10. Containers <br />11. Tod <br />12 Unit <br />13. Vdaste Codes <br />No. <br />T)pe <br />HM <br />and Pack ng Group (d any)) <br />Quafddy <br />V,R.M; <br />Ce <br />f <br />,0 <br />0 <br />gJr!XRCRRWA1Rf 3I+`:WA'�-i't,LIQ�1(01LYWA(ER} <br />'i' <br />r <br />E3 U 1 <br />T <br />{W� <br />Z <br />2. <br />W <br />3. <br />4 <br />4 Special Handfnq fratructions and Adational Informhon <br />t utEfi 4 9P I 1 T 1 " PR�f 11.E V 4P 1 ' At I Cir: 3M- E PA CUO S 9R11 n1)W- `APPROPRIATE, PERSONAL PROTED7TVE <br />16 GENERATORIVOFFEROR'S CERT!FiCATION: I hereby declare Gnat the contents ut this amslyonourd aou fully aril aatnakry du> ibed KWye trr tho IKu"I stippmu iumie, nowt ere cle9er;txt, pacAauadk <br />marked and fabeled'placarded, and are in oil respects In proper condition for transport acoordrg be applicable mtemabonsl and nabonig gavemmenlal regutat ons. If expnd shipment and I am the Primary <br />Exporter, I cortity that the aVents of the consgnmenl conMrm 10 the terms of the attached EPAAdu,anledgrranl of Consent <br />I cedify that the wasta mmunization s�lement odenlified In 40 CFR 262.27;a) (f I am a large quantity generator) or (b) (ii I am a small quan^zy gerewor) is true. <br />GeneralarsrOfio!pr-SPri" "Typed Name Sgna; o Month Day Year <br />/ <br />-j <br />16 Intematton Sh"ents <br />❑ Impnn In U S ❑ Export from U S Piet of er>iry/exit <br />z <br />Transporter signature (for exports only): Date leaving U.S. <br />w <br />17 Transporter Ad=,VudgmentofReceiptatMoterias <br />Transporter 1 PrinleNTyped Name Sgnature Month Day Year <br />Q <br />a <br />Z <br />d <br />Trans tar 2 Pan'edlTrped Nana 5ignatfae Month Divi Year <br />1P, Discrepancy <br />1Pa. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Res duo ❑ Partial Re;acfw ❑ Ful Rejacdan <br />Manaest Reference Number <br />18b Altervale Facility (of Gerrerewo U S. EPA ID Number <br />J <br />U <br />LL <br />Faaldy's Phone <br />Waro <br />1Bc. Signature of Alternate Facuty (or 6enerf) <br />Month Day Year <br />Q <br />Z <br />Ag. Hazardous Wasie Report ManagerInt Method Codes (i.e. cedes for hazardous tvasle area ment, disposal, and recycf rig systems) <br />2 <br />3 <br />4 <br />2 0. Designated Facuty Ownef cf Operator Certification of r�pi of hazardaz ma',eriats covered by Me manifest except as notod in Item 18a <br />r <br />me yped Name Signature Month Day Year <br />EPA Form 8700-22 (Rav 3.05) Previous editions are oWleta. GENERATOR'S INITIAL COPY <br />