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Please print or type. Form designed for use on elite 12 ricer. <br />Forth Approved. OMB No. 20500039 <br />EPA Form 8700.22(Rev.3.06) Fri adilionsare obsMe. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS I 1. Genefahu ID Nuym�ber <br />2. Pape 1 of <br />3. EmergencyResponse <br />b <br />WASTE MANIFEST �'nI I_CCI. 341 .�..,si�� <br />I <br />HitD 4124-WiCil :HEMIRE'C: <br />7-11 JJK <br />5.0enerator's Ne and Mallinglykkees I <br />Ct <br />Gererall See Address in ditMt Tan mating address) <br />/',I:, c'N.^rini eyIC.n <br />w/6. EE'. M1 /r -r L w1e_ <br />Caenrtelole Paoar. -a 4 a/j <br />6. Transporter l Company Name t.Rb Aet;A.PAFt4ViRi)tMF.IN1At SFRVi(it-PK: <br />t'Mww AW)V11$-33711 U.S. EPA ID Number L'ARtI(r(1 I'.1: 117 <br />7. Transporter 2 Company Ni me <br />U.S. EPA ID Number <br />8, Designated Fardlhy Name and She Address F _ lv t:tiP ., A <br />7.ROT7 lAvt:. U.S. EPA IO NumberC <br />Ri At 1A <br />' Af HN1:>444N7s <br />t)AVtp: CA {Q;ii1� <br />lesd1 a Phone: <br />Is, <br />96, U.B. DOT Description (Including Proper Shipping Name, Heard Clew, 10 Number, <br />10. CoaWMra <br />11,70131 <br />12. Unit <br />HM <br />and Padang Group (h amt)) <br />Quantity <br />Wt %. <br />13. Wpb OWN <br />No. <br />—Typ. <br />1. Ico;1.0t)0" Ill 1 114311111 94,3145, <br />an <br />15 <br />= <br />2. <br />W <br />U' <br />3. <br />oa4..�y 8ro ctptu ani Ad��na�In�mtago� <br />'VE hi; Pt I. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I rertby declare that the contents 04 this <br />con gnmenl are hity and acantely described above by the proper shipping name, and are dassi packaged, <br />marked and tebeleofoacarded, and are in all reaps= m proper oon icon for transport exordrig to applicable mtemallonaland rwtoral govemmental regulations. Ir export shipment and I am Te Primary <br />Exporter, I certify that the contents of OW consignment cmkrm to TB terew ofthe attached EPAAcilpeMdgment of Consent <br />I cerl that the waste minimization statement identified in 40 CFR 26227(x) (if I am a large quantity generator) or (b) (if I am a smal quantity generamr) is mine. <br />IorslOBames Printeo7Typed Name <br />SWUkkn Day year <br />III log I 1->< <br />18. International Shipments <br />❑ Ingdt to U 3. ❑ <br />Export from U.S. Pon dentrybdt <br />Transporter signature (for exports only): <br />Deb lmkg U.S.- <br />.S.17. <br />17 TmmponerAdmowleroMof Receipto!Matsiele <br />G <br />Transports l Prined/Typed Nerry,,,._( <br />Sipwtirre Month Day Wer <br />C1 I DI <br />Transporter 2 PHnletl/typed Name <br />Signature Mora Day year <br />♦ <br />18. Discrepancy <br />189. Discrepancy Indication Space ❑ Quantity ❑ Type <br />❑ Residue 7 - <br />LJ Partial Repdpn Ful RepcBon <br />Mai feel Referei Ni <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />V <br />LL <br />Facii Phone: <br />18c. Signature of Altemate Fadley (or Genaremrj <br />MenT Day Year <br />$ <br />y19. <br />1�L <br />Hazardous waste Report Management M*W Codes (i.e.. codes h hazardous waste treatment, disposal. and recycing systems) <br />C <br />1. <br />2, <br />3. <br />_ <br />4. <br />20. Designated Facility 0avwr of Operator: CerhBcetlon of neap of hazardous mushmals covered by the wiliest except as sad in Item 18a <br />P—,IWyped Name <br />3prleltrre Mnr%I' Day Year <br />I ' <br />EPA Form 8700.22(Rev.3.06) Fri adilionsare obsMe. GENERATOR'S INITIAL COPY <br />