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' 1 �«.f �. t dnJyG'r inn nn nllfw /a�'na..F\ hmeluri{erl I^ <br />Form ADDroved. OMB No. 2050-0039' <br />EPA Form 8700-22 ( e .3-05) Previous ec itlons are ob�ote9f . <br />DESIGNAIUD FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />�GU (1 OZ16, 569 <br />2.P'agllof <br />3EmergemyResporens Phone <br />qo-yh <br />4. ManifesthacWngNumber umber <br />0094-676834 J J K <br />5, Geisarators Name and MaillogAddreaeGmreretors Site Address thouterent man nagNg address) <br />s PEEFA. i�5 <br />/�.,. <br />, <br />2;; 1 z.'S', i:.>i IC' Y z r'4 z= '>.:.>TvcK;.�� <br />..e:: <br />Gereaars Phonii/ '^fix <br />S.Treasporter l Carhpahy Name :; ?ti U.S. EPA ID Number <br />E05 1? 9-7F e,41) <br />7. Transporter 2 Company Name '• U.S. EPA ID Number <br />req �• <br />' :��,. \J'C..•,...- �fr.t�'C?S ��7�N✓— '0��-: ��%'i0�` \�.1 if��"7� <br />. <br />B. Designated Facility Name and Sfte Address U.S. EPA ID Number <br />�I -ea rj F'{lLf or �' .. .. <br />i0;;t I &e rrr IS'G <br />pry, q <br />SQ. r7xwr-r'.0 e't o�5t'?i xL/ 40D OS94 <br />FbdBl sPhone: <br />9a. <br />9b. U.S. DOTDesalptlon ('ndudng Proper Shipping Name, Hazard Class, ID Nurnber, <br />10. Conalf- <br />%Total <br />Quantity <br />12. Unit <br />XMI. <br />13. Waste Codes <br />HM <br />and Packing Group (8 airy)) <br />No. <br />Typo <br />o <br />1.�}f, <br />3/)771 ;1,112ard L�fl.S P r� i1,olS,J <br />I <br />pr'I <br />w <br />. 4. <br />3. <br />4. <br />14. Special Handing babudions and Additional Information <br />15. GENERATOR'810FFEROR'S CER IFICATION: 1 hereby declare Ihatthe'contents of this consignmantare fully and acowam described above by the proper shipping name, and aro classified, packaged, <br />marked and Izbeledlptecdrded, and are In of respects in proper condition for transport according to applicable International and national governmental regulations. If sport shipment and I am the Primary <br />Exporter, I certIfy that Bre contents of this cdnslgnmenl conform tothe tans of the attached EPAAcknowledgment of Consent <br />I certify that lie waste minimization statement ldentlBed In 40 CFR 26227(a) 181 am a large quan0ygenerator) or b)OfI am a arson quantity generator) Is true. <br />Generators/Offerors Pdnad/Typed Name Signa 1 y /„ Monthth y YmY <br />16. International Shipments ❑Ireport M U.S. ❑ Export from U.S. Por(.nfJr Irykidt <br />Transporter dgnature (for exports only): Date leaving U.S.; <br />W <br />17. Transporter AGmowledgmentof Receipt of Materials <br />Transporter 1 PrinteciTyped Name Signature r Mona Day Year <br />­ �c �ts <br />d <br />3 Sr) >a\ke�oS aF /ti 7) 2 <br />2 <br />Tramporter 2 Primeygfyped NameC Slgnahaeif, Month Day Year, <br />✓ <br />r <br />} <br />18. Discrepancyu <br />18a. Discrepancy NdwI on Space ❑ O"ELY ❑ Type ❑ Restd. ❑ Padlel Rejection ❑ FIR Rejection <br />ManffW Reference Number. <br />18b.Alamate Fadtity (or Generator) U.S. EPA ID Number <br />7 <br />U <br />u <br />w <br />Fedlitys Phone: <br />16Q Signature ofNtemale Facility, (or Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (l.e., codas for hazardous waste treatment disposal, end recycling systems) <br />2 3 <br />4 <br />20. Designated Fadrily Omer or 0pemdr: C cation of mcelpt of hazardous materials covered by the manifest except as Med In Item 18a <br />P b <br />ad Name l S naltU�� _1 Month Day__ Tear <br />EPA Form 8700-22 ( e .3-05) Previous ec itlons are ob�ote9f . <br />DESIGNAIUD FACILITY TO GENERATOR <br />