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• <br />Please nrint or tvne (Form desioned for use on elite (12 -Ditch) tvaewriter.) <br />• <br />Fort ADoroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) PrevtouSedilions are obsolete. DESiGNAPED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS t. Generator ID Number 2. Page 1 of 3. Emergency Response Phone <br />4. Manliest Tracking Number <br />0 0 8 8 7 3 4 <br />WASTE MANIFEST <br />5 Generator's Name and Mailing Address Generator's Site Address (it diffemrs than maifaig address) <br />8W 0 <br />515ra wV <br />Staoktarb G196C�0B <br />Generator's Phone: themeffim <br />G Transporter i Comparry Narm <br />U.S. EPA IU Number <br />/p� <br />�i.1`i�7 <br />CW NQ <br />7. Tramponer 2 Cornpsny Name <br />U.S. EPA ID Number <br />8. Designated FOly, Name and Site Address <br />U.S. EPA ID Number <br />11 MW 8 soft <br />y. � <br />NV <br />%iY ii:a�JR�7 <br />p <br />Far��a� s �tiiae: <br />9a. <br />9b• U.S. DDT Descotion (including Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />ii.Tow <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />Quantity <br />WNoi. <br />t <br />„! <br />1. x+r»RG► H wale 1lgII>ci <br />i <br />f <br />j <br />I <br />LU <br />2 R1cln-RCRA Hazwdcms W (1Nar Based Paielt} <br />I <br />i <br />3 NA3077. HaMdow wade, stoma, N as»0ursenitc, Lead. <br />DOW <br />OM <br />DW <br />X <br />. a PG M <br />0M <br />4C 4t'-' <br />P <br />oo� <br />lei <br />4 <br />i <br />14. Special Handling Instructions and Additional information <br />Ptetjed Numbste' 8M Murnot * DIMS <br />1)EF 0101118�68�1� Oi101 <br />8Nj- '©Z>r% <br />/ X. Sb cam! <br />��7" <br />15. GENERATOR'StOFFEROR'S CERMCATiON: r y ec.are tat the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labetedrpiaearded, and are in all respects in proper condition for transport according to applicable in national govamnentat <br />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 Acknowl t of Consent <br />I certif Ne vraste m fnl6zoWn stat ment identified in 4g CFR 2b2.27(a) (it I am a W,jo quantity gonaid ) or lb) (4 i a q go, a :or) is true. <br />n a/ ore <br />No <br />fn DayYear <br />2 <br />18. Int is �dd'�'tt � import touts. t..! Export from Port W enirytaxl: <br />— <br />Tlplw si tore tv exports on! . Date leav . U.S. <br />w <br />17. TransporterAdmowiedgment of Receipt of Materials <br />Uj <br />T der t Mtedfryped N e pna. rQ <br />as DaY Year <br />Z <br />Transporter 2 Printedlryped Name Signature <br />Month Day Tear <br />18. Discrepancy <br />18a. Discrepancy Indication Space u Quantity ❑ Ty�pa Residua <br />❑ Partial Rejection <br />.! �r--tt <br />t..ul R*cfion <br />Manifest Reference Number. <br />18b. Atiemate Fadiny (or Generator) <br />U S. EPA iD Number <br />..i <br />U <br />LL- <br />Fac1 ;s Phone: <br />UQ <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />t. <br />Ao'�q <br />2. <br />40 <br />1 <br />3. <br />4. <br />2:7. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br />Puri yped Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) PrevtouSedilions are obsolete. DESiGNAPED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />