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Please print or type. (Form designed for use on elite (I24oh) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3 Emergency Response Phone <br />-i. <br />4. Manifest Tracking Number <br />WASTE MANIFEST -- <br />1 <br />y <br />,`. <br />0090,79243 JJ K <br />5. Generators Name and Mailing Address r•��; Generators Site Address (if different than mailing address) <br />Generators Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />B. Designated Facility Name and Site Address : i....; v' ;i <br />U.S. EPA ID Number <br />Faciliys Phone: <br />ga, <br />91b, 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( if any)) <br />Quantity <br />wt.Nol. <br />1. <br />Ell <br />K <br />� <br />z <br />2 <br />w <br />3. <br />4. <br />II <br />I <br />14. Speclal Handling Instructions and Additional Information <br />r rL.G r'I i <br />ENVIRONMENTAL HEALTH <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the orients of thiscoK-ffirlely described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, 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 orgy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I cediy, that the waste minimization statement Identified in 40 CFR 262.27(x) of I am a large quantity, generator) or (b) (ifI arta small quanfity generator) is Ime. <br />Generatorsi0fferurs PnntedlTyped Name } Signature, j <br />Month Day Year <br />-.a <br />F <br />16. International Shipments <br />❑Impart to U.S. ❑Export from U.S. Pod of entrylexit• <br />Transporter signature(forexports only): Date leaving U.S.: <br />17. TranspoderAcknoMedgment of Receipt of Materials <br />Signature <br />Month Day Year <br />Transporter 1 PrintedRyped Name <br />4 <br />Transporter 2 Printedrryped Name Signature <br />Month Day Year <br />IY <br />18. Discrepancy <br />I <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type Residue <br />❑ <br />El Rejection <br />j <br />Full Refection <br />Manifest Reference Number: <br />1Bb. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />E5 <br />LL <br />Facility's Phone: <br />w <br />18c. Signature ofAllemale Facility (or Generator) <br />Afonlh Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />u <br />1. <br />2. 3. <br />4. <br />20. Designated Facility Owner or Operator: CeNficallon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedRyped Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />