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Please print or type. (Form designed for use On elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Prpious editior's are obsolete. TRANSPORTER'S COPY <br />UNIFORM HAZARDOUS <br />1. Generator, 0 Number <br />2 Page 1 of <br />3. EmergencyResponse Phase 4. <br />Mw&d Traekvrp Number <br />WASTEMANIFEST <br />_ =i t '_ u r 7: 4 ', <br />, ( , - t" <br />2MWI <br />5. Genemlor's Name and Maung Address <br />Generewes Site Address (ddrlterertttitan IRErg address) <br />GeneraWs Phone' <br />i <br />6. Transporter 1 Campany Name i <br />U.S. EPA ID Number <br />Ir' 7 ' t <br />' .-J- t <br />7. Transporter 2 Company Name <br />/ U.S. EPA ID Number <br />S. Designated Facility Name and Site U.S. EPA ID Number <br />Fero s Phone: <br />ga. <br />9b. U.S. DOT Description (mcfudkg Shipping Name, Hazard am, ID Number, <br />10. Contairrers <br />11. Total <br />12. U. <br />13. Waste Lodes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Du- ty <br />WtNol. <br />Of <br />1 <br />- _... <br />:...4. <br />(. <br />2 <br />LU <br />� <br />I <br />i <br />3. <br />4. <br />14. Spedal Handling Instructions and AddrSona kdonnabon <br />15. GENERATOR'SIOFFEROR'S CERTIFIC TIOlk I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping rarne, and are dass6ed, packaged, <br />roamed and labeledlpiacaded, and are inrespects in proper corditiai kr transport according to applicable fterreticnal and national govern wrlat regrAatians. 0 export shipment and 1 am the Pm nary <br />F)orter, I cermfy that the coments of this wniban b the terns of theabc;hed EPA Acknowledgment of Consent. <br />I certify that the waste mant¢afion slalarr ent identified to 40 CFR 262.Z7(a) (d I am a large quantity, generaktr) or (b) (d I am a small quantity generator) is true. <br />Generator's1011erofs PnrredfTyped Name Signalune Month Day Year <br />.b <br />-1 <br />16. International Rtments ❑ knpo U_s: ❑ Ewort from U.S. Pat of enbylea <br />z <br />Transporter signal re (fir exports only). Date img U.S.: <br />Cf <br />17.TrasparlerAdcwledgmrddP—*d <br />WTransporter <br />1 Pmbed/Typed Name Skpnahre AIorM Day Yea <br />CL <br />Q <br />Transporter 2Avh dfTyped Name Signature Month Elay Year <br />18. Discrepancy <br />18a. Disrrepa cy Indication Space ❑ fity ❑ Type ❑Residue ❑ Partial R*cdon ❑ FW Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />v <br />tai <br />Fadkty's Phone: <br />W <br />18c. Signature of Alternate FacA'dy (or <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Codes (ie., codes for hazardous waste trnaahtertt, disposal, and recydktg systems) <br />1. <br />2. <br />3. <br />4. <br />20. Designated FKffrtyQwmor .Operator of recap[ otthis nnaWgis coveted by the manifest except as nded in ttem 18a <br />PrinteNTyped Name \ Signature ' � ,. y MCI* Day Year <br />EPA Form 8700-22 (Rev. 3-05) Prpious editior's are obsolete. TRANSPORTER'S COPY <br />