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Please print or type. (Form designed for use on elite 12 -pitch) typewriter.) <br />Forth Approved. OMB No. 2050.00 <br />EPA Form 8700-22 (Rev. 3-05) Previous tiditions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF RE0111RFD) <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1.eratod ID Number <br />C' P� L ODD <br />2. Page 1 of <br />3. Erne gen y Response Phone <br />50 -- +b3- a36`1 <br />4. Manifest Traddng Number <br />000257467 MVV <br />5. Generator's Name and MailingAddress Generatofs Site Address (if different than mailing address) <br />q LD S A L MA TO 7 I AL, MA-nIA 4 C W Al j LU - 16 It, !� i3 PoA-fl4•.,'-" -}1, u <br />I K4B, IQ • 9&C u A -y s <br />s•t oc rc,A►, - S-taL1�'i� <br />Generator's Phone: y • i� S — <br />6. Trans <br />er 1 Compa y Name <br />U.S. EPA ID Number <br />1 <br />7. Trans orter 2 -Comps ny Name U. A umber <br />8. Designated Facility Name and Site Add <br />GRAN ' I� <br />s U.S. EPA ID Number <br />,415-00yV4 <br />� i Lv d 1^� Lu% <br />.'rl 113 �' <br />Fa r s•Phdrre-`.' <br />) <br />ga. <br />9b. U.S. DOT Description (indudnglProper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unci <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nd. <br />,. <br />3� <br />Z <br />LLI <br />2. <br />3. <br />4 - -- <br />14. Sppeeciaal�ll}Handling Instructions and Additipnal Information <br />C 16-V <br />q <br />15. GENERATOR'S10FFEROR'S CERT( (CATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and ara in all rasps= in proper condition for transport according to applicable international and national governmental regulations. N export shipment and I am the Prknary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAckrowledgment of Consent. <br />I certify that the waste minimization statement dentified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offerors Printed/Typed Name , 7 Month Day Year <br />n ,"2 � W iP - <br />7"� <br />16. Inlemar5dnal Shipments pot to U.S. ❑ Export horn .S. Port of entry/exit <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. TransporterAdcnowledgment o(Receiptof Materials <br />tE <br />Transport 1 'nted/Typed Name Signature nth Day Year <br />1 <br />Jr <br />Q <br />Trans 2 'n] oypecilvarne <br />Signal Day <br />tY <br />a^ <br />16. Discrepancy <br />18a. D %cmpancy Indication Space M Quantity ❑ Type ❑ Residue ❑Partial Rejection Full Rejection <br />Manifest Reference Number. <br />18b. Aftemete Facility (or Generator) U.S. EPA ID Number <br />J <br />C� <br />_ - <br />LL <br />Facility's Phone: <br />W <br />18c. Signature ofAltemate Facility (or Gen tor) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLA <br />L <br />2. <br />3. <br />4. <br />20. Desgnatsd Facility Owner or Operator, Certification d receipt of hazardous materials c vexed by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous tiditions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF RE0111RFD) <br />