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Please print or type. (Form designed for use o" efite.(12-Ditch) tvDewrfter.) From Amr .d ()AAP fd� 'XQIM40 <br />EPA Form 8700-22 (Rev- 3Z5) Premous editions obsolete <br />TRANSPORTER'S COPY <br />UNIFORM HAZARDOUS <br />1. Generator 1P <br />Number <br />2. Page <br />2. Page 1 of <br />Emergwq Response Ptx <br />------ ---- <br />Manifest Tracking Number <br />WASTE MANIFEST <br />'DC10 <br />2: b <br />14,Manifest <br />00025763 M wl <br />4 <br />5. Ge waWs Neme and Marg Address <br />C..W. Site Ad mw (d &Wwd Ow mak@ address) <br />7 1, <br />Gw*.mtWs Phone. ti" <br />6. T= Na" <br />U. <br />7. TrwRWter 2 Company Nam <br />U.S. EPA ID Nwn6er- <br />8. Designated Faak Name and Site Address <br />U.S. EPA ID Number <br />FaciWs Photo-, <br />9& <br />9b. U.S. DOT De9crip6on (fivW"xrig <br />PIr <br />Name, Hazard Class,ID Number. <br />10, conuners <br />11. Tow <br />12. Unit <br />13. Waste Codes <br />NO. <br />Type <br />HM <br />and P -JON Ca V ar'Y)) <br />QU-* <br />WLA1bL <br />iA <br />2. <br />LLJ <br />0 <br />3. <br />4. <br />14 HarAng Instruchora ardAddllional Wortriation <br />L <br />15. GENERATUR'SA*TEROR'S CERMICATION: I hereby declare to the conteift of this corsowmnt are A* and accurately described above by the Vow shipping mme, and are dasdied, packaged, <br />marked and labeledipiacarded, and are respects in proper corxHon for transport woordirig to applicade imernaborW and national governmentalw regutaboK export shipment and an the PmTwy <br />DpGrter, I oer* that the abritents al r: coubm to the term of the aft3ched EPA Adamwiedgment of Carseat <br />I Der* that the waste idertillw! in 40 CFR 26227(a) (i I am a large Wm* generator) or (b) (d I ama small quar* generator) is true. <br />Gererato "ierces ftftdfTyped Name Swab- motith Day Year <br />A <br />—1 <br />I- <br />16. international Shipments <br />Dimport U.S. D Export from U.S. Pon of entrVe)ot <br />T-WWK VratUre (for 6XPDft -)Y): Date leaving U.S.: <br />17. Trartsporter Acknow6dret of Reo* of Ma" <br />-payi — <br />T:n Sigriatureyw <br />CL <br />co <br />f AV ur <br />L <br />Tramporte?2 Prirdodffypad Karff sig"Oure tbrM Day Year <br />18. DisQepancy <br />18s. Discrepancy hdication Space D miny El Type ❑ Residue El Partial Rejection Elo Rejection <br />Mwifest Reference Number. <br />18b. Atterrmle F acifity (or Generator) <br />U.S. FPA ID Number <br />1L> <br />Facility% nw.-- <br />Uj <br />18c. Signature of Ahmate w - <br />FacHity (or Generator) <br />Month Day Year <br />19. Hazardous Waste Report Mgement Codes (i.e., codes for hazardous waste treatmeK dispwal, and recydirig systems) <br />C3 <br />1. <br />2. <br />3. <br />4. <br />20- Designated Facility Owier or Operator- Ce ti6gr6on of recW of hazardous matNiift fit try Ore maniest accept as ---'in Item t8a <br />Printadfiyped Name Skstaere Month Day Year <br />EPA Form 8700-22 (Rev- 3Z5) Premous editions obsolete <br />TRANSPORTER'S COPY <br />