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Please Print or type. fForm designs for use on elite 12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />(Continuation Sheet) <br />121T Generator ID Number <br />22. Page <br />23. Manifest Tracking Number <br />24. Generator's Name <br />Number <br />25. Transporter Company Name y �1 A s/4 <br />t G <br />26. Transporter Company Name um er <br />27a. <br />HM <br />27h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group if any)) <br />28. Contain -'s29. <br />Total <br />Quantity <br />30. Unit <br />Wt.Arol. <br />31. Waste Codes <br />No. <br />Type <br />/alNi <br />%//.%[.vy/r-f <br />LES 1 <br />Liv d <br />0 <br />0 <br />z <br />w <br />z <br />w <br />c7 <br />32. Special Handling Instructions and Additional Information <br />33.Tmns der Acknowled ment of Receipt of Materials <br />W <br />n <br />O <br />Printed/Typed Name Signature Month Day Year <br />M <br />Z <br />34. Transporter Acknowledgment of Recei t of Materials <br />F- <br />Printed(Typed Name ignature Month Day Year <br />J <br />U <br />Q <br />LL <br />O <br />W <br />Q <br />t7 <br />35. Discrepancy <br />36. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />N <br />W <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />