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Please nrint ethane IFnrm desinned low use nn elite 119 -mi tvnewrifer I ` 'g+ Fn.m 4nnrnvuA ri mR Mn gnrNMtn EPA Form 870D-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3 Emergency Response Phone 14. Manifest Tracking Number WASTE MANIFEST It (.' 1 1 10) 11 l j i01 t -f- riPd3 0 084 }1 2 ". �e Q 6 J J K .t lors 5. Gen caName and Mailing Address Generators Site Address (if different Nan mailing address) Generators Phone: - i 6. Transporter I Company Name U.S. EPAID Number I thi .. , .,l NIAL. SERVK; ING IRM -4S , A V 0 0 0 1 1 '1 it 1 -, 7. Transporter 2 Company Name U.S. EPA ID Number L -.1'4V C ,i I! I tt i!<;"1!tii. C A R D 0 0 1 ? R it 2 8. Designated Facility Name and Site Address U.S. EPA ID Number Ii.. f: C.(:)1{)C::, I'-:. l 85 1'IM1 r; OF 1'.'.. RI AS fly N'J 891- ):', Facility's Phone: 77" .fi ., .''" IJ 141 T -, .5 1_' (} 1 fit 0 o Q Re gb. U.S. DOT Description (including Proper Shipping Name, HanN Crass, ID Number, 10. Contalars 11. Total 12. Unit HM and Packing Group Cd any)) Quantity WINOL 13. Waste Godes he. Type K 1. K Z X. W CD 3. 4. 14. Special Handling Instructions and Additional Informalbn t \ftl.l rat `:'71 I .. .1'.)tt{: � t 1 tt 1INPLANOU31- �l 1 k'1: 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acouratedy described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are In all respects in proper condition for transport acconfing to applicable International and national governmental regulations. If export shipment and I am the Primary Exponer, I certify that Ne contents of this consignment coMonn to the terms of It a attached EPAAck aridedgmenl of Consent. I pertly Nat he waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) IliI am a small quantity generator) is true. GenerxtorsrOfferors Prinled/fyped Name Signature Month Day Year Ir. t J ra r 16. International Shipments ❑ Import to U.S. ❑ Fxportfrmn U.S. Pod Z of entrylexit Transporter egature (for etyoris only): Date leaving U.S.: w 17. TransporterAcknoxiedgment ofReceiplof Materials Transporter 1 Printecirryped Name Signature Month Day Year Go f f r T�.. ;.-1.1 ! F=-` - t Iii 6 Transporter 2Prinwrrned Name Signature Month Day Year K 18. Discrepancy 16e. Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑Partial Rejermion El Full Rejection Manifest Reference Number. 18b. Alternate Facility(or Generator) U.S. EPA ID Number J U rax. Facllilys Phone: w 18c. Signature ofAhamale Faoiity(Or Generated)Monthay Year Q Z m19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 4. 20. Designated Facility Omer or -Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 S Prinledityped Name Signature Month Day Year EPA Form 870D-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY