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cq 16 3 7 SS 3 -vs / Please print or type. (Form designedfor use on elite (12-pitc, ,ewdter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Po e 1 of 3. Emergency Response Phone 4, Manifest Tracking Number 000894539 F L E WASTE MANIFEST C b vSv 3 5. Generators Name and Mailin Address Generato's it Address a different than mailingaddress ^ 40.4 rA, Mailing Address A '• �(I HB!!/a N S ��lL %y 6a Lsl,v aorc `J4$^J40.4 (gra �, NQ ,2o? 17i � t- 0A1Z'VEy L" Kron3 oARS�i1 r -OD -Tr C/i 17S21ry G$(ieratars Phone:1, 9. Aj , o& G 6. Transporter 1 Company Name U.S. EPA ID Number qP> &v2u1c�5 c hi+D 0:35 a77Sv 7. Transporter 2 Company Name U.S. EPA ID Number 8. ed Facili Im6eQand Spa Add�reSyijylvU.S. EPA IO Number ?�8,5j2�11[[JJ5 13ll-I E9+� F61 y's Phone: p C4 kf ( 016 y 9a 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing if an 9 Grou P f Y)) Quantity WtNol. g 1,itiA 4 o (QUG0 C(, CANO A,U Nd5 D�eHW�2¢A S u,��SI w/zc L! 91 out 2./AiIv��T Wwl 6./ ua�99i �1lIRk�5� I 3 A (Z �7 (dlJ So tGJ I vfy?� �p P 4. AIN( yAAiu1 ;,dt^ko-) P 14. Special Handling n`st'mdi and Additional ation ?> CCL 5 �U Z ef/ 2 0�� x&S �z�� hr 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, marked and labeled/placarded, 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 Exporter, I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. I cemly that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator( or (b) (if I am a small quantity generator) is true. Genemator'sO erors Parisi Name Signature Month Day Year o (0 I (`] O �j 16. International Shipments ❑ Import to U.S. ❑ Export from U.. Port of entrylexit: Z — Transporter signature for exports only): Date le .S.: LJ 17. Transporter Acknowledgment of Receipt of Materials K Transporter I Prriin�te Name Signs ur Monthay Yeaarr7 qyped z Q Transporter PrinledfTyped Name S natu Doth ay Year K H 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑Type❑ Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q �- Facility's Phone: w 18c. Signature of Altemate Facility(or Generator) Month Day Year z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1* J4 I 2. 3 . 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item laa Printedifvped Name Signa re Month Day Year mMIC IL u �ucv D ///167 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)