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Please print or type. (Form designed for use on elite (12 -pike, .,pewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />(Continuation Sheet) <br />21, Generator ID Number <br />! ' '-I <br />- 22, Pag <br />O} ^� <br />23. Manifest Tracking Number <br />24. Generators Name <br />25. Transporter p <br />ny Name <br />tC' 0 JjQV Y15 - oiV. <br />f <br />W fC <br />U.S. EPA ID Number <br />0 0 <br />" 0 <br />26. Transporter Company Name <br />U.S. EPA ID Number <br />27a. <br />HM <br />27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />28. Containers <br />29. Total <br />Quantity <br />30. Unit <br />Wt.Nol. <br />31. Waste Codes <br />No. <br />Type <br />K <br />0 <br />W <br />z <br />W <br />32. Special Handling Instructions and Additional Information <br />a, <br />33. Trans orter Acknowled mentof Recei t of Matenals <br />QK <br />a <br />Pnntped Name r <br />¢fna! — <br />Month Day <br />Yey, <br />Z <br />34. Transporter Acknowledgment of Receipt of Materials <br />r <br />Pnnted/Typed Name <br />Signature <br />Month Day <br />Year <br />J <br />U <br />Q <br />LL <br />0 <br />W <br />35. Discrepancy <br />z <br />f7 <br />36. Hazardous Waste Repel Management Method Godes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />N <br />W <br />e , <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />