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�l I ,M iyyi{ r�•• <br />Please print or type. (Form designed for use on elite (12 -pitch, .,,,ewriter.) <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05T Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />� <br />CANIII <br />2. Page 1 of <br />3. Emergen Response Phone <br />-:'1 <br />4. Manifest Tracking Number <br />000358846 FLE <br />WASTE MANIFEST l <br />G_ <br />5. Generators Name and Mailing Address ,l Generator's Site Address (it different than mailing address) <br />loaqul+l `.rG.il((�� lrd LUdSIC yj Uil '� �I IhlnlbrC� {�Ilf�ri`�JS <br />1FIp JrA J(X)Ll rl Co. <br />`7 <br />IILuSelwlr{ LLb-jj t-Ct <br />x <br />�oYs'PftorkPC�� �f^(.ox <br />f c l CA ci-.5 r5� 5 Q.N. l <br />45f[& "11- , <br />GeneTaf- ,?UI ,.. <br />6. Transporter 1 Company Name <br />U.b. trA 10 Number <br />c C. <br />r <br />-;. 314 c <br />7. Transporter 2 Company Nafm�e� <br />U.S. EP ID Number <br />`- W <br />8. Designated FacilityName and Site Ad ss <br />U.S. EPA ID Number - <br />umberor\111G <br />0 1) 1 11 GL- I- - <br />11tnt(} N. A>tuS R.c1 <br />Fadli es Phone { Q -) '7 <br />Ll' -11 4 ' - <br />9, <br />91b. U.S. DOT Descripti n (Including Proper Shipping Name, Heard Class, to Number, <br />10. Containers <br />11. Total <br />1 12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (I any))w� <br />Quantity <br />Wt.No. <br />S <br />�hrar y IVfed iC2)GOGi bxirirlyy'F <br />0l(c <br />w <br />tJc n��T' e IQiNd mctkPr �[ <br />r <br />GG <br />F <br />2 (,Shgr� NFc{If_, nncl ��yy, I,,r�PS) <br />G�.I,t`c;+ i;erulai�l n1CCtPrlCtl <br />I� <br />uoi4` <br />�::, r <br />eOl,CblDilllUif?-1 1711.S�1E'I,yI:J,��(i1�c1,Cj Utl_'� <br />F l L) rc-s <br />� <br />�nl <br />, <br />r t <br />4. 1VDN DG1'ri'qulGl(1d rllulc-I I0I,(U1jlV:e,3 l <br />tkxsiel Fluor pSC.rrl+ fJUIbs) <br />co <br />14. Specter Handling Instructions and Additional Information <br />1 } L N .9� 1 t.rJ-1 _1�i_ X .3QbF -t L t-! :"i .tet C:tO-1 _Lj_ X C N _1LIGt., <br />V 55bO <br />N}l Vla11Cce, _A4- xtl <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acwmtely described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental <br />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 EPA Acknowledgment of Consent. - <br />I certify 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) <br />is true. <br />enerator erors Printed/Typed Nameigna re <br />Month ay ear <br />'Z <br />16;1 Motional Shipments - - <br />Import to U.S.❑ Export from U.S. Pad of entiylexib <br />- <br />Trans orter si nature for ex ns only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />IX <br />Transporter 1 Printed/Typed Name Signature <br />Month Day Year <br />- <br />Qrensp <br />rter2 riot Na�r{Signature <br />omth ay ar <br />cz <br />18. Discrepancy <br />t <br />18a. Discrepancy - <br />❑Quantity ❑Type' ' - ❑ Residue <br />❑ Pallial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Facility <br />Alternate (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />Facile gPhope <br />r� <br />18c. SigllatulIXot&ltemate Facility for Generator)7, 7Month <br />Day Year <br />Q <br />z <br />U2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />'� <br />1 <br />2. I 3. <br />1~/LrNV1 1 <br />4. <br />20. Des(gr(atedF ity Owneror`V*alor Cefficelion.djaelA f_,hazandous materials covered by the manifest excel as noted In Item t6a <br />PnntedfType Name D Signature <br />�D )) 111 U <br />Month <br />Day Year <br />m <br />EPA Form 8700-22 (Rev. 3-05T Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />