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Please print or type. (Form designed for use on elite (12-oil..,ev riter.l <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1. Gene r ID Number <br />1167$0� <br />2, Page 1 of <br />3. Emergency Resn Phone 4. Manifest Tracking Number <br />e - 37 001039591 FLE <br />WASTE MANIFEST <br />5.. Gen WIL 40 �and Mailing V Qress �y � ` S Generator's Sit Q eys (if_di9eraW il� <br />1�/. V'w'Oj,/ 73 G /V�ll-%F! / � fJF- <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />r. l N "AVOIZZZSJ <br />Z Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Fadli N��Sit rid s�U.S. EPA ID Number <br />rrgg <br />/Zq.J�n%VI �?nnr,//f/7 <br />`�rvL� <br />Yr <br />Facility's From . 71 1) ( �% 9� %(7 ) <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />WtNol. <br />13. Waste Codes <br />HM <br />No. <br />Type <br />o <br />f 3, X493 <br />6� <br />,5 zres� <br />�fIAQfll/ p <br />J <br />P <br />tia <br />clso uQul 5 ct/��v <br />• -57w <br />�/ <br />. 6" c.B7 Wu Pcj r- <br />3v <br />4. <br />CIVw <br />14.5 eti andlingInstructions and Atl lioPalInformation 3 C,WByv63d l y�,Y <br />5 C'N7,-io&V3� /wS� <br />700 7-V0&74'/yMr3�°� !�xfCf yip k33' <br />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, <br />marked and Iabeledlplararded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedg nt of Con . <br />certify that the waist nimization statement identified in 40 CFR 262J7(a) I am a large quantity gene at or (b) if am a sm [qua generator) is tree . <br />Generet is O eco s P Monthgna ay Year <br />, <br />: 4 WN C-'ee" C <br />1B. Intion (Shipment <br />LJImport to U.S. ElExpom .S. Port of entry/exit <br />Z <br />Trans ortei si nature for exports only): ale lea <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transport <br />1 Printed/typed ame Signal on ay Year <br />y <br />U00 ( II t o <br />QTransporter <br />2 PrintedlTyped Name ig ature onth y Year <br />K <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑ Fuli Rejection <br />Manifest Reference Number. <br />18h. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />V <br />Q <br />LL <br />Facility's Phone: <br />w <br />18c, Signature ofAltemate Facility(or Generator) Month Day Year <br />Q <br />.. <br />Z <br />19. Hazardous Waste Report Manage end Method Codes (i.e., codes for hazardous Waste treatment, disposal, and recycling systems) <br />1. <br />414411 <br />2. <br />3. <br />4. <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedName Signature onlh Day Year <br />1111 L D / D% <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />