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Please print or type. (Form designed for use on elite (12-pitch,-ypewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. '- DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />an <br />'A(1 <br />UNIFORM HAZARDOUS <br />1. Gene r I10 ,Number <br />��f�llo.yr. <br />2. Page 1 of <br />1 3. Emergency Response Phone <br />4. Manifest Tracking Number_ <br />000854537 FLE <br />WASTE MANIFEST <br />:- <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) tttmhim itirC\ <br />:,,.,(111 Co- -)o l J WbtiilL�obion Lc_ r_igC�Tr-- )1— ei bla+(ot-) <br />U +fix lg1 a i-oueloce, <br />Road <br />t� 11 <br />Generators Phone: of N CMd.. '3Nle= Mien <br />A P5 a q 577 <br />6. Trans der Drapery time <br />i, lean harbo <br />nu)r menta Serv(cft <br />U. S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8.,D@signated Facility Name and Site ess <br />n Jcxtc�u(nHHW( <br />U.S. EPA 10 Number <br />Si• R A ?6rlcl e�FU—C�� 5/�� <br />�R G <br />�1 f� I` 1 /�^ /�' I <br />` <br />`�., 100 0 <br />Facility's Phone: J V (.X J1' ..C�UIO <br />r` k1 f 1 V i <br />9a <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 />12. Unit <br />13. Waste Codes <br />No, <br />Type <br />HM <br />Quantity <br />WLNaI. <br />0 <br />1Flo bfnable 1�1�j(klcl,n•o-5.,3�Un Iqq� �G11 <br />(�1a <br />; <br />37— <br />IN <br />IC IC��J74—� UICjf� dGrhfltG.�J��;iuir , <br />�� �GZtC�/rethrins, <br />� <br />I <br />, <br />� <br />7S <br />AI <br />4�-4rL�tE��+Fi <br />n- - - <br />I <br />N <br />14..Special Handling Instructions and Additional information/ t <br />C Nays^ L Fb i k --- }C-4+�+C +�=_-� k <br />,, 3 )C <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consignment are fully and a urately described above by the propWifili6iong name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicablememational and national governmental <br />regulations. If export shipment and I am the Primary <br />Exporter, I cerlify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I call that the waste minimization statement identified in 40 CFR 261 (i( I am a large quantity generator or (b) am artily generator) <br />is We. <br />eneratosl erorsar!Typed Name 1911 <br />ry-, -l-.r/ ��j - OGS <br />ant ay ear <br />/o' /n D7 <br />y fY r '-/� <br />j16. <br />H <br />International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pod of entrylexit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Rece_iptof Materials <br />K <br />Transp9djI Printed/Typed Name _ Ignatur <br />Month Day Year <br />GTransporter <br />2 PnntedlTyped Name t Signature <br />Mont Day ear <br />K <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type El Residue <br />1:1 Partial Rejectien ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />Q <br />r+- <br />Facilit sPhone: <br />w <br />Q <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C <br />1.2. <br />` <br />I4:l <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 iso <br />Printed/Typed Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. '- DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />an <br />'A(1 <br />