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JI 1, <br />Cf `, <br />Please print or type. (Form designed for use on elite (1 -pitch) typewriter.) <br />Form Approved. OMB No -050-0039 <br />EPA Fornr, 8700-22 (Rev. 3-05) Previous editions are otbsc*te. DESIGNATED FACILITY TO GENERATOR <br />s <br />-UNIFORM HAZARDOUS <br />1. Generator ID Nu <br />Z. Page 1 of <br />3. Emergency Response PFiohe4. <br />-0166 4353 �� <br />WASTE-"IFEST <br />r ; t <br />5. �x and Filing Address - s _ ' (If different than malting address) <br />C CA $ice <br />Generators -..,-..... aF <br />6. Transporter l Company fthe"IIS EPA NWbeirrc ; <br />7. Transporter 2 Company Name U.S FPA ID Number a <br />rhmn hWbars <br />+, LLC- CADNM757M <br />1 St L13k" flltt <br />9AW44ft, ort WM <br />ga. <br />9b. U.S. DOT DesdgYjon" fndudng 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 Pa6jrV G -p (d any)) <br />Quantity <br />Wt-rVol. <br />1. ? f rr?t ,� er fs Wgsis <br />{ Fiilr sr th <br />Iran <br />w <br />Z: <br />2. <br />UJ <br />3. <br />j---1--- <br />4_ <br />1 <br />14. Special Handling lnstructionsand Additional lnforman <br />15. GENMTOR'S/OFFEROWS CERTIFICATION: I hereby declare that the contents of tlis cortsigrlrrtent are fully and accurately described above by the proper shipping name, and are dass4ied, packaged, <br />marked and labeledlplacarded. and an, in all respects in Groper condition for transport a=&lg to applicable intemationa! and national governmental regulations. If export shipment and I am the Primary <br />Exporter. I certify that the cordents of this consignnutnt conform to the terms of the attached FPA Admowledgrnerd of Consent <br />I certify that the waste minimization statement identified in 40M 262.27(a) (if t am a large quantity generator) or (b) (if I am a small oAantfty tor) is true. <br />Gene PrintedTyped Name Signature EMonthDay Year <br />}Offerors <br />V <br />-i <br />Z <br />16. International Shipments <br />❑ Import to U.S. <br />❑ Export from U.S. Pok of entrylexit: <br />Transporter signature (for exports only): <br />Date leaving U.S.: <br />w <br />17. Transporter Adutowledgment of Receipt of Materials <br />- <br />I- <br />Transporter 1 Printed/Typed Name <br />Sig a .. Month D Yoar <br />a <br />Z <br />a <br />Transporter 2 PrintedlTyped Name <br />na re Month Day Year <br />rr <br />t- <br />18. Discrepancy <br />18a. Disaepan cy Indication Space ❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />tar <br />Faditys Phone: <br />W18c. <br />Signature of Ahemate Facility (or Generator) Month Day Year <br />Q <br />Z <br />y <br />19. Hazardous Waste Re Management Method Codes Le., codes for hazardous waste beabnent, d <br />Pori nagem ( sposal, and recycling systems) <br />1 't {J� <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Certification od, receipt of haardoils materials covered by the manifest except as ntted in stern 18a <br />Pfmledlfyped Narne � �9�n' w Month <br />Ycar <br />EPA Fornr, 8700-22 (Rev. 3-05) Previous editions are otbsc*te. DESIGNATED FACILITY TO GENERATOR <br />s <br />