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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. I DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator 9 Number Gp/- J� �j �L� 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin Number 0003 8823 FLE WASTE MANIFEST epD e7 .Ly ivv�Slo%v 5. Generator's Name and Mailing Address Generators Site Address (rf different than mailing address) till jo qW, "uh r;K 1-ella-f—A c r. %QA �✓i�`�7J�Ti0 l�!/o�.NAzd�zeN 23z3 coc��-i> Generator's Phone: � ;f✓(pG 6 Transporter 1 Company arae U.S. EPA ID Number C145-hlJ11wi M?hb d3 YxZZ50 7. Transporter 2 Company Name U.S. EPA ID Number 8. D nate Fa ityllN�ame`a`n �SiA tltlfes �r U.S FPA ID Number / .%/%m�fl��PPr-cam N Facility's Phone. -L!/j-I?- Ap by 9a 9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class. ID Number. 10. Containers 11, Total 12. Unit 13. Waste Codes Nq Type HM and Packing Group (if any)) Quantity Wt.NoI. Ir Erna naaaca a u �� N 3 u �rr�NBL-� pe'lJotHa �5 6/2 , w 2. Q PeillC4 rSLjgVfV CipMn/p9LS 7 rC. b.. i u^S 3 j/; LS7 ,Z 3. (ur,-fro aLi 4m7,y) t.-�> I, <(J 4& Z,[- A C'1�FL,P L, 4Nt+� x4yW< C �<Vlls Lt A-) l7,i (AA' / &vZ' / j�F'l� � --- y`/ S- / A�W 14. Special Handling Instructions and Additional Information S�21►PR/)vF�o<z� pi -F, ivlfo�llHBitAx-, �� NAL9/LL�r`S mo7,�v�� . wASz�/S 4iCo-A EX&wP7 f- "-s'J 0i . Z -(-/.S<(6)(/) Xc?(r/S 1vJ t c�I357�WBS�9cica^(i 4 C461rt7 C'76 H� <Zb L ) •Ag V' , 15. GENE OR BIOFFEROR'S CERTIFICATION: Iherehy declare that the contents of Nis consignment arefully and accurately described above by the proper, shipping name, and are classified, packaged, marked and labeledlplacarded, 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 candy that the contents of this consignment conform to the terms of the attached EPAAcknoWedgmerd of Consent. - I cer ify that the waste minimization statement identified in 40 CFR 26227(a) (d I am a large quantity generator) or (b) (it IF a r1all qu y generator) is hue. GeneralorslOfleror's PrintedRyped Name igna ure on ay ear J Z 16. International Shipments ❑Impact to LLS. ❑Export from S Port of entry/exit. — Transporter signature for exports only): Date leavin W 17. Transporter Acknowledgment of Receipt of Materials Trans 1 Pti^^nle--d7F''y ame SignaWr on ay Year O N //rt�er U 4-0 IlZ Quo �O QTransporter PrintectTyped Name Si attire Month Day Year K H 18. Discrepancy 18a. Discrepancy Indication Space. ❑ Quantity ❑ Type ❑ ResidueEl j ❑ j Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U a �- Facility's Phone: w 18c. Signature of Alienate Facility (or Generator) Month Day Year Q Z N19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment. disposal, and recycling systems) 0 1, 2. 3. 4. I 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest cep s noted i lam 10 41 Pri d Name y� /� Signat U �d' a Month Day Year '. JVI� '1 i ,wr, .�,_% 0 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. I DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)