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<br />' Please print or type. (Form designed for use on elite (12-pitob, awriter.)
<br />Form Approved. OMB No. 2050-0039
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<br />EPA Form 8700-22 (RaV. 3-05) Previous editions are obsolete. / ' DESIGNATED FACILITY TO GENERATOR
<br />UNIFORM HAZARDOUS
<br />1. Gene for O Number
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<br />2. e 1 of
<br />3. Emergency Response Phone
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<br />4, Manifest TrackingNumber
<br />00038781 FLE
<br />WASTE MANIFEST
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<br />3-3-7i•
<br />5. emtoes Name and Mailing Address /1 Generapis Sm Address(it different than m�aili�n�g^address)
<br />Grl �Ci� a rrl l t it „111)r C"... �f1C:M11 PuaS LlI) J_) -Z L4II (. c- NhSGV tract
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<br />Gene. eif flS 1'Gi.1 J�0'lki
<br />8. Taporter 1 Company Name - U.S. EPA ID Number J D-
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<br />7. TranspoDei2Co � -A'L ; US. EF77
<br />B. Designated Facility Name and Site Address /_ ` U.S. EPA ID Number
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<br />W99 Hmemcan Circ kr-
<br />FaciliVs Phone: F-Ictoral r•'' I SCa -� I 3 IZ �7�
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<br />9b. 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 />Wt.Nol.
<br />13. Waste Codes
<br />No.
<br />Type
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<br />14. Special Handling Instructions and Additional Information
<br />1. C.N,�'tOCs2) 1�. X 5� �m j r� . CHa..'�f�(U„25 aN X Cr��Ylr3 3r C NayU(�a•Go �x � 11rr1
<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 cassiffed, packaged,
<br />marked and labelediplacarded, and am 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 tens of the attached EPAAcknowledgment of Consent.
<br />I candy that the waste minimization statement identNed in 40 CFR 262.27(a) (if I am a large quantity generator) or,(b) (if I am a small quantity generator) Is true.
<br />Generato eras Printed/Typed NamePrinted/Type -: ley Signature Month Day Year
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<br />16. International Shipments
<br />❑ Import to U.S. ❑ Expod from U.S. Port ofentry/ex8:
<br />Transporter signature for exports only): Date leaving U.S.:
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<br />17. TranspoderAcknowledgment of Receipt of Materials
<br />Transporter 1 Prmtedf yped Name Signature Month Day Year
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<br />Rrinted/T d Na e r Ignatu f J/ /1 ^",,F ? on j a ear
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<br />18. Discrepancy z%
<br />18a. Discrepancy Indication Space ❑ Quantityyp I
<br />❑T a ❑Resitlue Partial Rejection Full Rejection
<br />Manifest Reference Number
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<br />led. Alternate Facility (or C odj..,, � ys„„. ,,.�•x y,✓✓�� U.S. EPA ID Number
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<br />Facility's Phone:
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<br />18c. Signature of Alternate Facility(or Generator) Month Day Year
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<br />h19.
<br />Hazardous ste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />2. l 3.
<br />4.
<br />20. Designated Fac ityl0wneror Operator: Certification of Ipi of ha' mous materials covered by the manifest ceola noted in Item 1Be - \
<br />Printed/Typ Nam Signatu
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<br />nth Oay Y ar
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<br />EPA Form 8700-22 (RaV. 3-05) Previous editions are obsolete. / ' DESIGNATED FACILITY TO GENERATOR
<br />
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