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Please print or type. (Form desioned for use on elite f 12-nih ;writer 1 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />li <br />UNIFORM HAZARDOUS f. Generator ID Number„wr, <br />2. Page i of <br />3. Emergency Response Phone <br />V •amu. v,,u • V..�..�-V�e� <br />4. Manifest Tracking Number <br />WASTE MANIFEST 1 - ) `h <br />'� " �� ',�.-� I <br />000358832 F L E <br />5. Generator's Name and Mailing Address Generator's SheA dress (H igerent than mailing address) <br />Sa 1 joa 11) CUTt�1 l� ntF�r�� kdiew3 , K ; <br />U , <br />Jun )cam Uut (� iku�kX.M ,1C44:a( 0US Lkit5f <br />1310 I-Iciri'mdar <br />Sr'SPh'ofiE'i U Pl C A y �J � i� I r f'r �ar t! 1 T l t <br />Ge at I t° � fC'P 1 <br />6. Transporter 1 Company Name - U.S. um er <br />bot t; E not r <br />7. Transporter 2 Company ame U.S. EA umber <br />- 6 -- lt)D(v y3 o30 H8 <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />C' l;�Cftti tlaf -;Z) !EtwifoomPnlad Sde <br />-11-1 <br />Fac's�f��ArinlU f4r 30 i - -144L. <br />ga <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if anyj) <br />10. Containers <br />it. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />1. y4Spllr�,%IC:.NjGnB. <br />,(ery.ld�,�i�1�eNily(lb•�1 <br />� <br />2. i}{�Il\III-�kIFI l�}TCC10lt,�J,t1;11a71O�J,��irf <br />n <br />f bcp-5V I{(oar-tCerr3!Ia8)(Pr.CH940C.1,5 <br />3. PINI Kir Re(ATeb MATMal,3,Lin I Ito 3, p<,Jr <br />N <br />r` <br />(errj:I�Sife�M:CN�I''!G(oa(o1 <br />�!}` <br />G <br />n105 <br />14. <br />14. Special Handling Instructions and Additional Information <br />, C F't�l'-dOla �3 1 X 55 Dn1 •.�.� C! ki�yc�C15 -� i�YV'1(3C:,�" 3.)c�HdKOio:�co <br />I <br />atr ' C -T lit a44fi <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping nambiand are classified, packaged, <br />marked and labeleclplacarded, 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, 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) (t I am a large quantity generator) or (b) (if I am a small quantity generator) is We. <br />Generato s erofs Printecirryped Name signature Month D,, Year <br />I fill <br />J <br />Z <br />16. International Shipments <br />Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />-I <br />Trans iter si nature for exports only): Date leaving U.S.: <br />Ulu <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pli bairryped Name Signature Month Day ear <br />y <br />I - F' l>3� k 0 <br />aT <br />nsponer2Prin yped Name �--.y Sgnatum on ay ear <br />�, cI,cl t 1 D /6 6 <br />Discrepancy " <br />I18. <br />18a. Discrepancy Indication Space ❑ Quanti❑ Residue <br />ty ❑Type ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facill 'ePhone•r:cay ry ,.....,.-usti - w:,:.;;i •�•"'„ <br />W <br />180. SgnatyCe ot.dJmt �pr nemfor c:. ,py4r�n, Month Day Year <br />Z <br />K..? <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. _. _ <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Cedificabon of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br />Pdn edNpier. - h t , Signature t Month Day Year j <br />l �t <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />li <br />