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-, 6-_ 1C__ f- "­ — a- H 'DAt'hl fuswm6farI <br />Form Anoroved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev, 3-05)' Previous editbirts are obsolete. DESIG14ATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />*r _12� <br />Page <br />Response Phone <br />Mantleal Tracking Number <br />e1 <br />1 0 0 3, 2 0 9 FL <br />WASTE MANIFESTK21 <br />IRM -MS <br />Ck <br />5. Mm—ralor's Nano and Mailing Address Geneirators She Address (if dillierent than milinig address) <br />j,s-opq Te In. <br />SAMWAY <br />C <br />StmMm, A SM <br />Generators Phar: 91 <br />6 Transporter I Ccmpanynarne U.S. EPA ID Number <br />AApmed C'Undow TIM40t br, 13V) <br />7, Transporter2 Company Name U.S, EPA ID Number <br />6. Deskjnated Facility Name and SiteAddress U.S. EPA D Number <br />AJJKMDW (3mv=1 Tmaim"A <br />6133 E91h Bhd NE <br />'Namwerem-,NM BMW <br />Fac;!!N�sPhcme: OV443494=1 - <br />98. <br />9b. U.S. DOT Desiaiplian (including Proper Shipping Name, Heard Class, ID Number, <br />10. Contamers <br />111. TOW <br />12. Unit 13, Waste Codes <br />No. <br />Type <br />and Packing Group (if any)) <br />Quantity <br />WUVO. <br />W"fe p,t r's WWaTtaw. 3 KA <br />OF <br />p Mal <br />0 <br />LIU <br />z <br />2. <br />w.r <br />3. <br />,i Spect-al-Handkg Instructons andAddlional Information <br />ftim, <br />IMRM2A <br />AC-T43MIS <br />15 GENERATOR'SICIFFEROWS CERTIFICATION: I hereby dedare fit ft contents of this consignment are fully and accurately described above by the proper shipping name, and are 6assified, padcaged, <br />marked and labeled/placarded, and are in all (aspects in propar condition for transport according to applicable international and national 90VUMent8l regulations. 9 export shipment and I am the Primary <br />exporter. I certify that tie contents of this consignment conform to the terms of the attached EPA Acknowledgmart of Consent. <br />c6#dy that the waste minimization statement identified in 40 CFR 26227(a) (if I an a large quentity generator) or (b) (if I am a smaP, quantity generator) is true. <br />Month Day T <br />aerator — ped ftneear <br />JLY <br />_j <br />iry Kertfational Shipments ❑ 1-0-1 to U.S. EExport from U.S. Port of entry"exit: <br />z <br />Transporter spature for okports only): Date leaving U.S- <br />9Z <br />17. Transpoft AckmwWg ment of Receipt of Materials <br />rUl, <br />e <br />0 <br />Tr4nu r 1 Signature M64i Day- Year <br />Yrte 111 yoec Nall', <br />h Y <br />Transports;nspTransports;2 PfinlediTypadjame Signatup', Montay ear <br />Dscre;ancy <br />ItE. <br />18a Discrepancy Indication Space Quantity FIT}w 1:1 Residue Elloarfial RejectionRA Rejection <br />Manifest Reference Number. <br />18b. Alternate Faa!ey (v Generator) U.S- EPA ID Numm <br />Facilq's Phone: <br />Lu <br />lEc. Signature of Alternate Facility (or Generator) Month D4 Year <br />!a <br />z <br />S2 <br />Co <br />19 Hazarcs Wasle Report Management Method Codes rte., codes for waste ireatmard, disposal, and recycling Systems) <br />cu <br />LU <br />4 <br />. <br />2c', Hest tee F=Ily owner of Cipplor: Certification Of rp* of nawdow rnma covered by she memdest except as noted in flern I§a <br />PnnfedlTyped Name signabire r tln Day Year <br />EPA Form 8700-22 (Rev, 3-05)' Previous editbirts are obsolete. DESIG14ATED FACILITY TO GENERATOR <br />