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4 <br />ia <br />;le se print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1 -'Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />­ 'I JJK <br />0 7 013 0 6 9 8' <br />WASTE MANIFEST Y <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />d5 <br />S <br />Generator's klhef!�`Ay144 <br />6. Transporter I CompanFNaRe-- U.S. EPA ID Number 7 <br />7. Transporter 2 Company Name X%jLj%-,,fJ—J-L V U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S..EPAID Number - <br />P "1 Financial Services <br />AV N 4 <br />CAD N108.6741 8 <br />Facility's Phone: <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers 11. Total <br />12. Unit <br />13. Waste Codes <br />HM <br />and Packing Group (K any)) <br />No. Type Quantity <br />Wt.Nol. <br />0 <br />Ulf" , <br />0 j <br />ul <br />7—, <br />2. <br />J_ <br />3. <br />RECI <br />A <br />4. <br />UI Ita <br />P" <br />rees <br />I <br />band <br />S e <br />747S—pecial Handling Instructions and Additional Information <br />_(1— 4_�114'11T/ ------ <br />;3-, <br />D U es ',,order <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignm6nft are fully and accurate iy described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, 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 <br />Exporter, I certify that the contents of this consignment conform 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 I am a large quantity generator) or (b) (if I am 6 small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name signature Month pay Year <br />7;1 <br />=j <br />16. International Shipments <br />El import to U.S. Export from U.S. Pon of entry/exit:­ <br />Transporter signature (for exports only): Date leaving U.S.: <br />LLI <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day <br />0 <br />:Year <br />44 <br />M <br />Transporter 2 PrrhtedJrfyp6d t4me Signature Month Day ear <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity R TypeEl Residue El Partial Rejeti.n El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Q <br />u- <br />Facility's Phone: <br />0 <br />uj <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />V) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />1. 35'_', <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by.the manifest except as noted in Item 18a <br />Pdntedrryp me. Month Day)Year <br />N'S <br />1 _7 161111 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />