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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator 10 Number e4000:) &-7 -3j O&9 2. Page 1 of 3. Emergency Response Phoria A Manitesl Tracking Number 4 9 01369 FLE WASTE MANIFEST 5. Generator's Name and Mailing Address 2A A,0 OAA) W- AJ A Generales Site Address (if different than mailing address) +140-7 S &A,e�+ 63-c S• AvavzA Sr 1+tODt yTO, eA 9.5354 STa Lfcr o.J �iA 9S2v3 Generators Phone: Z04^SS%-�I , 6. Transporter 1 Company Fame U.S. EPA ID Number r40✓ANL915 eH E..+r CAL-r(LAA.15 to a T eAp00007 O.SNO 7. Transporter 2 Company Name U.S. EPA ID Number CA -9A^) 14AZO-011 EAIv19VAJ1nf1/-rAL -iE Vtcfi TA/L r✓lAA03g3222S-O 8. Designated Faality Name and SaeAddross U.S. EPA 10 Number GLEAwI )4,44000.;. o r SC,J 703c , LL L 4021 Pj 4912 &,j LSSA QOA0 ' 40AJSosE, e4 9s133 G4�Os94gK3fp Facilit's Phone: D I - O Z go. 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (it any)) Quantity Wt.Nol. c1N26-72 :t- -r Aa am020nVIA .10LV-r 0A)l P OoO� 127- . 220 w 2. v11+4g,3 tjAS'T9 Ir LA A9 L6 Lt 22UI ds Ooal Z1� A-0.5., r , ,�onr 900 P 3OAJ 12(p3fJ AiTf PA/AJI (L rLATcO r✓IATE21AL 1 f,y q00 p ' I CV-S9F'oo3 3, PG a Qa (ovo1) 3 COOS 33 + 4. VAS 1263, WASTE PA/.j-r Ie CLAFTFq 14ArEZrAi-A 000) '� FinS X 3. PGs Ra (0001) 6bo 14. Special Handling In�st/ryuctions and Additional Information E26 8 IS4 E Ei $ 11.Q, +�Ce�4ja4-SP; LCe23 ZA6_001 (I'tS5 4/r) -.1) C>fs22-619 ; PAG -ooh (I ASS 0/-r) E26 1117$ r" d x 10 3�er1s�1261y ' iif-da3,ov4, 42 Or 01-r) 14)e"-57220001 rade-oa6-d7G17 2 ss'/r 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national govemmental regulations. If export shipment and I am the Primary Exporter, I codify, that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent I certify, that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity, generator) or (IbUll am a small quantity, generator) is We. Generator's/ emes Print ypName ON 4EFAAL-e OG /LAA0A4V1C 1gna re ear lG4 o 0 71 International hipments Import to U.S. ❑ Export from U.S. Port of erilgexib Z Transporter sinature for exports only): Date leaving U.S.: W 17. TrensporterAclannaedgment of Receipt of Materials Transporter 1 Printed7Typed Name gna ure on ay Year y730�� iYo-�i l.� i'0, � 6 0.2 11 QTmnsporter2 rintedfTyped Name ignature onl ay ear K r 18. Discrepancy 18a. Discrepancy Indication Space ❑ QuantityT Residue ❑ Type ❑ Ll Partial Rejection Full Rejection Manifest Reference Number: 18b. ARemate Facility (or Generator) U.S. EPA ID Number J 0 ra+• FacBi s Phone: Ise. Signature ofAIlemate Facility (or Generator) Month Day Year ¢w Y N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) - W 1- 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a - Printadrryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)