|
Please print or tvoe. (Form designed for use on elite f 12-oitcht tvoewriter.l
<br />11111111111111111111111111111111111111
<br />0 0 6 5 2 0 8 0 1 S K 6
<br />Form Approved. OMB No. 2050-0039
<br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete.
<br />) IGNATED FAVILITYTO DESTINATION STATE ff SEQUIf3ED)
<br />UNIFORM HAZARDOUS
<br />1, Generator ID Number
<br />Tv #(71Z1i €rl� t
<br />2. Pag f
<br />3. Emergency Response Phone
<br />- :.Jlij,r... - , 1-
<br />4. Manifest Traekin Number
<br />o o s o s o 1 SKS
<br />WASTE= MANIFEST
<br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
<br />t.: Y." V l '�`'r' r1 L"YS C 'hi`" r�rti'- id r '--hr
<br />:.$ %_YI• F _•.('.l_%_l�.�ili � i ._� t t_�._1� � l::t,..: 4�t't:� t. i )`�'i Fl-.. C.. r...:'�7
<br />`i}
<br />._) F i.l
<br />"In GE)LUP BLUE,
<br />SAL 1 D0, f 1 r„ 5
<br />._. ,..
<br />Gonarator's Phone: a�, ..;..._ _! G,
<br /># _ ? _M5.,717-18
<br />6. Transporter 1 Company Name
<br />U.S. EPA ID Number
<br />C•y'-'-;f _..1./ r•,._"N �1"
<br />:''�i
<br />7. -Transporter 2 Company Name
<br />U.S. EPA ID Number
<br />f_.0AN' ;3("jI;`130R'., r.-1°i1,J.1Rfjf.1Ml t;lT, L s,C=fw zr'JPC._
<br />B. Designated Facility Mame and Site Address
<br />U.S. EPA ID Number
<br />Facility's Phone: `
<br />ga
<br />9b. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />13• Waste Codes
<br />No.
<br />Type
<br />HM
<br />andPackingGroup (if any))
<br />Quantity
<br />xNoi,
<br />11:
<br />1.
<br />4lwid.-{ iii `ii :.:� -«S .f"i, t
<br />i`+ 1p'I-.. i.7 r'['%f"+ Lt`]'i: sr:rTi{�1 i�' 3 SL"� -r_, r'r_�' (.1)
<br />(4Jif;•�II�I,_),�(1� vi,,�1.r, � 11',F,' t 1! Yi ('
<br />3((1
<br />/1�'�/
<br />1
<br />P
<br />'r,'y_'�'
<br />LE!
<br />2.
<br />La
<br />3.
<br />4.
<br />14. Special Handling Instructions and Additional Information __ t
<br />r•r.• _
<br />`✓s Vi� 1--Mi_€_;l"r_ ,i_..;j 'll •_81,710- 7t1r3•_ "'G,0 CIA ' S f ' � }
<br />.J
<br />f4!1'i• r1C; ��:1# ", F s q V l` s-'` %'d-'C"�-: 'i',
<br />15. GENERATOR'S10FFEROR'S CERTIFICATIQN: 1 herehy declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,
<br />marked and labelecilplacardad, and are in all respects in proper condition for transport according to applicable international and national governments[ regulations. If export shipment and I am the Primary
<br />Exporter, I certify that the contents of this consignment cnnferm to the terms of the attached EPAAcknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if t am a large quantity generator) or (b am a small quantity generator) is true.
<br />G era rslOfferors Pri /Typed Name signature
<br />Mo h Da /Year
<br />^`
<br />2SI' ( ! S
<br />.t
<br />16.Inte%allon.j,111lipments ❑Import to U.S. ❑ Expert from U.S, ort of trylexit:
<br />Transptore (for exports only): 0 ving U.S.:
<br />W
<br />17. Transporter Acknowledgment of Receipt of Materials
<br />TrarimM,er 1 PrinladfTyped e Signature(Mo
<br />tYr y Year
<br />a
<br />Pd ypad Na Signature
<br />sporlerrinte
<br />Month_ Day Year
<br />Y
<br /><Tra
<br />Cr/s 1
<br />18. Discrepancy
<br />18a. Discrepancy indication Space
<br />❑ Quantity ❑Type El Residue
<br />❑Partial ReJeclion
<br />El Full Rejection
<br />Manifest Reference Number.
<br />g
<br />1 8b. Alternate Facility (or Generator)
<br />U.S, EPA ID Number
<br />U
<br />Facility's Phone:
<br />rird
<br />w
<br />18c. Signature of Alternate Facility (or Generator)
<br />Month Day Year
<br />`~d
<br />Z
<br />y19.
<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />Hi© 1. d
<br />2.
<br />3.
<br />4,
<br />20. Designated Facility Owner or Operator: Cortincation of receipt of hazardous maladals covered by the manifest exce not in Item 8a
<br />da
<br />Printed/fyped f-� Signature
<br />A'a
<br />Month Day YearIALM,
<br />I I
<br />1AIi/L -4
<br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete.
<br />) IGNATED FAVILITYTO DESTINATION STATE ff SEQUIf3ED)
<br />
|