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ori,. la— rnrneo nn olito N9,irh) wnewriterl Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS..: 1 Generator lD Number 2. Page l of 3 Emergency Response Phone 4. Manifest Tracking Number DAT WASTE MANIFEST - ' 1_-1 00: � -_ 5. Generators Name and Mailing Address - - - Generators Site Address lit different than mailing address) Generatort 6. Transporter i Company Name - U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number Fadli sPhone: 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. 'Haste Codes No, Type HM and Packing Group (if any)) Quantity WL/Vol. 1. O Q e . 2 2. W C7 L 3 i 4 14. Special HandffftgX Inc"agdAdditional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descrbed above by the proper shipping name, and are classified, packaged, marked and Iabeledloscaded, 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, I certify'that the contents of this consignment conform to the terms of the attached EPAAcknonledgment of Consent'--' I wilily that the haste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or(b), (Irl am a small quantity generator) is We. Genereldes/OSero's Printedlryped Name ..;SignaWre -_ .....— .. Month Day Year i— 16. international Shipments❑Exportfran U.S. Port of ent /exit El import to U.S. ry = Transporter signature (for exports only): Date leaving U.S.: w 17. TransponerAcknosledgment of Receipt of Materials � Transporter i Printedlfyped Name Signature - Month Day Year a' n Transporter Pnnledlfyped Name SigniWre Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type Residue Parfet Rejecion Full Rejection Manifest Reference Number, 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V Facility's Phone: w 18c. Signature ofAltemate Facility (car Generator) Month -- Day Year a Z N19. Hazardous Waste Report Management Method Codes (,e., codes fa hazardous waste treatment, disposal, and recycling systems) C 1: 2. 3. 4. 20 Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a -� Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR