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_cj1gsg4g9 _ gol <br />`Please print or type. (Form destgded for use on elite (12 -pita., , Awritec) <br />V Form Approved.OMBNo.2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. IDESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. nem ID Number <br />I <br />2. Page 1 of <br />22, <br />2�.yE,m�er�gen�cy Response Phone ��^�` <br />3 f 1 P <br />4. Manifest Tracking Number <br />000358843 F L E <br />WASTE MANIFEST <br />VV �)� <br />' Y..rl_i q- <br />5. orators Nape and Mailing Address Gene tots Site ddress (if d'Merent than malting address) <br />JGtI .Xk-'t(�U (0 0+(� �ti N �S'nlhfA �11( reU?� , <br />naquut t.v t�✓u. lfU�l +: .�i(:4QrJ�1� <br />8L FIG�fI�pl�_ 1Xut <br />�C: <br />�Sv�o tLrl Lla f� , r,(2A, 1f3riC7 G((o <br />Gene t s n : JtiJ ..,+�.\[1tL.� !`f`" <br />6. Trqnsporter 1 Company ame L U.S. EPA ID Number <br />f 4.�-' 1li,i1 V <br />7. Transporter 2 Company Name U.S. EPAIDNumber <br />8. Desi@rated Facility a and SireA drm U. EP Number <br />°16-(AI1 Oot ix;:` L 11ul 6011I�1��t, .�r�,c. _ Ap 6yS5c,3F1py� <br />30ci qI1*fIC00 Q..1cc it <br />Facility's Phone: -� o r •� I :� 1`' I' I`� <br />ga <br />go. U.S. DOT Deschption (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Cedes <br />No. <br />Type <br />HM <br />and Packing Group in any)) <br />Quantity <br />Wt.Nol. <br />1.' �lat1)fI� Jbf(e[ I C, ,d, n.c,:)-) Thlnf1er5,1 <br />ga <br />A1`,�111L 1�-1S �TGaal ) ,:3,� igCA31VG Il (ef6j <br />z.F_Icathnlu�l�.y'1;d�,c�lrcklz,c..,n.u.^.;•.+;K.eslrl:�. <br />i� <br />�. <br />X <br />tic�hc� �-(..a1-tivv)I yy.��u t3a5 (�i�tCer3.I.;3 <br />CtO� <br />fig <br />Ii <br />TU1GZlylor?� -:o1) <br />1),LAngq Z (36 <br />X <br />A) ,I(ZI (e <br />I)�p <br />�> <br />Joie <br />%( <br />Rf,� <br />X <br />In,IdGLole),t�,un 3�,ia7, er�.isa�(tyF atiw <br />GU(v <br />u� <br />0 o <br />14. Special Handling instructions and Additional Information <br />1 .) c N:a4Cxnl"i 619 55 hlp: <br />4.) c_ H 34r(P-5 , 4)' 55D11F cea , s'/�/8 R SCiCr�rao-sc� C�WS�j( i9 c i <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 classified, packaged, <br />marked and Iabeledlplacarded, 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 <br />Exporter, Icertify 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(x) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br />enerators(Offemrs Pnnte yped Name Signature on y ear <br />*110 <br />i— <br />16. International Shipments <br />Importto US.❑Expert from U.S. Port of entry/exA: <br />Transporter signature for exports only): Date leaving U.S.: <br />Ulu <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/typed Name ignatureont ay ear <br />ansgoder 2 PdntedRyped Name Signature.-. Month uay Year <br />Discrepancy <br />t18. <br />18a. Discrepancy Indication Space ElQuanfity Q Type ❑jj Res��idffue��{❑ Partial RejectionElFull ReocherAil/) <br />..� c. �. 4.1 MaAithst'Ftefe7ee N01116er.) <br />Illb. Alternate Facmor Ge or) I U.S. EPA IDNImboir <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of /blankets Facility (or Generator) Month Day Year <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />1 <br />If <br />20. Designated Facility Owner Or 0' erdor Certification of regeipt of hazardous materials covered by the manifest except asm6sd in Item Ise •- <br />Printedlryped Name ,.` Signature Month Day Year <br />I c <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. IDESIGNATED FACILITY TO GENERATOR <br />