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lease t EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR A) a pnnt ur type. trurmes uIpuku lot use un cote t izpuoi . .wnmr.) _ ' ..,"w"—.. •.. ' UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST C1 K .az. 000894524 FLE 5.Gnemtor's Name and Mailing Address Geneddor's Site Address in ditferent than mailing address) cAI � 11) CI ltit��lrt�l�l) Ntit'l itiNllL)rcC fi11C}rFIEL .�C11C� .C1. 6GX 1�'Ili SA 1)-1Gaqu Ir) C.0 liwSF 1-I'Id ux/JE ForII 5� 1�1 i r� C Hl c15'acc 1 SGL. y '� !0 1(� s. k bfIc to t St , Genemta s o 6. T Po er 1 Company a e _ /_ U.S. EPA IO Number I�P. �c cF I� Ill 7. Transporter 2 Company Name U.S. EPA ID Number -C 1-r '�rg B.D �?Valed Phoifirty Na`me crdgufte'Addr `� r— t e �1 PQ11 it r11)Ltry f�11UIr C:tTt4tFfliC.ki �PYv1LP_' Cillll)�)Gl�f- (III Facii 'S.�hoh6.JQ 1I , Nt. L� -q Iy r �L I Cl ga 9b. U.S. DOT Description (including Proper Shipping Name, Heard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 1TGrn+)rabl� rrga cj)n.rJ.s•IiTh,nnets,\\ '''ArGleutll IctG311)G c 'A bo a) Iii jT`Yt10.�r'_:CkHcrJt��t 11 l)r `10 ) ag el f cit I -� ' W �l c w w 'Fl nit)lGl)I� Su1.C1)LiCIGnIL,n•GJ•,CL�f Adrlt SI ✓� C,K Hlw 1 ).J L . 1 11- � I txi I! G I FI iCH4(a€ 5 !tt fy 3. Gj If- l'C"'d,4<_>IIC_II-), LG ^�14ir+1 tl:1G�t�llCrttawl t L,J06q r�(�, G'IL46C {� rc 4CL(V,cy,'IV 1' tatci Ixisl�,vl< ntG }Il c."j,, CGlyraxallnellmi`e-Lle)8U1)3�(a-1 `� 'i Z ? 1 1 FSG II UG } FH C�Ji tQ.,ySpeual Hantll g InstNGions an Add" nal in/ormaticn I ) CH.1-lulu, 41xt Tri wu ll? 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and am classified, packaged, marked and labeled/plassi ded, and are in all respects in proper condifion 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 allachad EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (R I am a large quantity generator) or (b) ('d I am a small quantity generator) is true. G_ene_rat stvuhmror's Pnnted/Typed Name Signature Month Day Year c I bV - ra It J 16. International Shipments 1:1 import to U.S. ❑Exponfrom U.S. Port of entry /exit: Z Transporter signature for exports only): - Date leaving U.S.: W 17. TranspolerAcknowledgment of Receipt OfMateriqf_1 Trunsfillyar 1 'med/Typed Name Signatur ear GTransportert 2 Pnnted7Typed Name -- Signature x Doth ey Year ` ✓;. ria 18. Discrepant^/ •` � - 18a. Discrepancy Indication Space El Quantity ❑Type El Residue Partial Rejection ❑Full Rejection Manifest Reference Number. 18b. Alternate Facility(or Generator) U.S. EPA ID Number J Q Q aL Facility's Phone: w 18c. Signature of Ntemate Facility (or Generator) Month Day Year Q z y 19. Hazard1�oltus Waste Report Management Method Codes (i.e., codes for waste treatment, disposal, and recycling system's) �h{afzaardous J 20. Designated Facility Owner or Operator. Certification of recelpl of zardous materials covered by the manife as noted in Item 18a Printed/Typed Name 5ig�r Month Day Year ` ` Y) Y EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR A) a