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df Please print or Nee. (Form designed forr use on elite (12 -Dila ,ewritec) L,�'-%r . C.CD r..r Jjr V ✓ Form Approved. OMB No. 2050-0039 EPA Pon 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS 1.Brat IDN be \' O 2. Page 1 of 3. Emergency Response Phone` I G J—'I` 4. Manifest TracklngNumber I F L E (0 3 41 WASTE MANIFEST L8 5. Generator's Name and Mailing Address Generator's Site Address is(fl erenl than fling address) JQI] 30CLqu,I) 0b �+1ubr'a Andrrw5 SGIfl JC�z "-' �0- kX45d)Cu GJQS1C- 1'8iC Hn�+all FCAC0It+ �r;dmSi- �vn�b50 Si -A fc Gene;&k>I C 6. moner1 Company Name - p 7f ki,) �Acwl orc I~ I� r JVD n U.S. EPA ID Number i11�iLaG c_ _� 7. Tmnsporter2•Sompany Name - lrx JLii,%r%l1-1j�/ U.S. EPI61b , o3599,4 B. Designated Facility Name and Site Address - (,IIPGrl I�adi�ol� �nulrorrn,er�lal e��',c� U.S. EPA ID Number 3()4 �nl"r+CGil Cfrc1E 1 ry Facility's Phone: r r I 7 C 11] 1! /�1,(J�' LI r 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) 10, Containers 11. Total 12. Unit 13. Waste Codes HM No. Type Quantity Wt.Nol. 0 Qmabl�. a d-o-S•��Ttiinitcr'S, elroleun 1 m l 1�. 1ShlilateSCH)4w,31UnM310611 (ecq%Jag) Liu F: CN Ai4 0 (AI l�G �F UIaW RI w 2F`IQnlnrul�l�501, ,G nor:.,FI.O.S-,{�FSt��SF�ih�'i!r PGU— (�,I�. (eft); 133)r(PfX49140WI UI GF I IBJ 3.*�CY FlGnuial)lit, LItuid I[,xit-.oS.(R/ reihe ril )(ti°r31), ! U1 zrIic" ( HNW ),3lnfl Gq,�,lp UU`I �M U19 ~t� �I" LL X 4. \ jk. J A 1 V 14. Special Handling Instructions and Additional Information F- �?.) C ht ��lol�(7 13 x M w r 5K0000ticU ' C. 1+ Q 4vCssa. c! x 55 D —pAra_>_l 74S(Oa-7 IJ•i UAA 15. GE ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acciundely described above by the proper shipping name, and are classified, packaged, 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 Exporter, l certify that the contents of this consignment conform to the terms of the allachad EPA Acknowledgment of Consent. 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 genemtor) Is true. - GeneratorslOHemrs PrintedlTyped Name Signature on ay Year I {111rril . IU ( v; El 325167 -116. z International Shipments ❑ import to LLS. ❑ Export from U.S. Port of entry/exit: Trans orter si nature for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Matedals Transporter i Printed/Typed Name ,+ r) ianature �rlt� I on ay ear 0 y t2(�co aA 1A S 0 z¢ Transporter P6ntedrryped Name / ignat re on ay ear Mk7',aAlA Fiv4Q),4.MJ '1 5qm 8/3 -r6 t le 30 07 ? A2 - ,c rllneuk - a 18. Discrepancy - Ise. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection 4/ ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility(or Generator) U.S. EPA ID Number J rrs+� q"14A ell''4 ra+- FacilitysPhone: W 18c. Signature of Alternate Facility (or Generator) " :1 Month Day Year Q z 19. Hazardous Waste Report Management F1e'tM1bdlCotiea (i:.'rlodes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 4. 20. Designated Facility Ownerbr Operator. "en8atiortaPt#bf Ra i�st�nals covered by the manifest except as noted in Item 18a Printed/Typed Name Signature onth Day) Ye ei EPA Pon 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR