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Ll <br />Please print or We. (Form designed for use on elite (12 -pitch) typewriter.) <br />W'S C - 0 01!-D 2 9. 2 4.2'---4, <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) brfevious editns are obsolete. -'r- <br />- ' <br />10517.1994 DESIGNATED I:AC T® DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1• Generator ID Number <br />9 <br />2. Page 1 of <br />3. Emergency Response Phone <br />s3A-,�6a <br />4. Manifest TrackingNumber <br />0 0 0� 3 9 9 4 0 G B F <br />WASTE MANIFEST <br />.�a�v< <br />awn <br />5. Generators and �� Generatoes Site Address (d different than mailing address) <br />99.6 Va1i1a Z l Z/ ' 9oJ� <br />� v v1�-0 <br />y$-" tii�n e s GA 9 r5FD <br />^ <br />Generators Phone: -70 - p 4OL <br />6. Transporter 1 Company Name U.S. FPA ID Number <br />,q oIG ,,etd 9,6kv#eq 64.0 9V669So'D6" <br />7. Transport r 2 Company Nanus U.S. EPA ID Number <br />8 e ' ed Facility Name and S'siAddress U.S. EPA ID Number <br />X-4 <br />O y / /�p� <br />%a'vh7'la�j�pvs+i�i l C4• QO(044U%(1 P <br />Facilitys 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 />and Packing Grasp (I any)) <br />Quantity <br />Wt.Nd. <br />coo l <br />Grri <br />Z <br />W <br />2. <br />3. <br />14. S Het inslru ' d'gal Information <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dere that the nts ofthis consignment are fully and accurately described above by the proper shipping name, and are classified, paclaged, <br />marked and labels ftlacarded, and are in all respects in proper according to applicable international and national governmental regulations. If export shipment and I am Due Primary <br />Exporter, I certify that the contends of this consignment conform a terms of the atter EPAAcknow�gment of Consent <br />1 certify that the waste minimization statement identified FR 262.27(a) (rf I am a large gtan' ge tor) or (b) (rf I am a small quantity generator) is . <br />neratorster�s Prirded/Typed Name Month Day Year <br />Wa Eth 3617 <br />J <br />r- <br />16.Intematioal Shipments' <br />❑ Irsgwrt to U.S. ❑ Export from U.S. Port of entry/e& <br />= <br />Transporter signature (for -pods only): Date leaving U.S.: <br />W <br />17. TranspoderAcMaMedgment of Receipt of Mates <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />R <br />d3 30 10q <br />Za <br />Transporter 2 Printed/TypedSignature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Resdue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />L) <br />FaciliVs Phone: <br />u®j <br />18c. Signature of Atiemate Facility (or Generator) <br />Matth Day Year <br />Q <br />Z <br />19. Hazardous Wase Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyclN systems) <br />C <br />1. <br />2. 3. <br />4. <br />20. Designated FadWOwneFor Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in <br />PrintedfTypedN Signahae Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) brfevious editns are obsolete. -'r- <br />- ' <br />10517.1994 DESIGNATED I:AC T® DESTINATION STATE (IF REQUIRED) <br />