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v <br />Please print or type. (Form designed for use on elite (12!Utch) typeWtiter.) <br />so E TSC.01G82. G74& <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />e ► ej • rr� - '10 : rr, C•, <br />UWATE M NFRSTU Number <br />2.Pa�1of <br />Emergency Response <br />4 Manifest Trading <br />G B F <br />® <br />5._GeOeratw NaNme anLd M t7 A� p Generates Site A (it �tferen n mailing address <br />oe <br />y <br />® 11nn 0 <br />® x P®® ® 1P1. l <br />OY <br />a l� T <br />Generator's Phone: — ?Y_ - <br />6. T sporte 1 Company Name ' ` U.S. EPA ID Number <br />p ` <br />® N``�" fO <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. D ' ted Facility Name qpd Site Address U.S. EPA ID Number <br />adtity's Phone: — 4 I <br />9a. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and PeckingGroup (if any)) <br />14 <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />WtNol. <br />13 Waste Codes <br />No. <br />Type <br />oQY <br />P <br />Ix <br />W <br />/y <br />Wd® <br />L <br />2. <br />69 <br />14.soacialand I in tier <br />15. GENERATOR'SIOFFEROR'S CERTIFICAT119K I hereby declare that the conte ft of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledfplacarded, and are' respects in proper condition for transport according to applicable international and nam governmental regulations, if export shipment and I am the Primary <br />Expoter, I ce* that the contornts consignment conform to the temps of the attached EPA meet of Consent. <br />I certily that the waste minim' ' statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if i am a small quantity generator) is true. <br />Gen sd Name Signature Month Day Year <br />t�Gue, ?Cmice. X 1� X o3 102 <br />J <br />F <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />= <br />Transporter signature (for exports only): Data leaving U.S.: <br />W <br />17. TransporterAdarowiedgment of Receipt of Mads <br />rX <br />Transporter 1 Print Cyped Name Signature MonthDay Year <br />a <br />y <br />s � <br />`1 0 „1 <br />Transporter 2 Printedffyped Name Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fug Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />FadWs Phone: <br />LL, <br />18c. Signature of Alternate Facility (or Generator) loth Day Year <br />Q <br />' <br />2 <br />N19. <br />Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recydin9 systems) <br />® <br />1. 2 <br />ko <br />2. <br />3. <br />4. <br />20. Desigiuded Facility OwN or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />7yped Naps S Signature 6j�� <br />twn6�— f<w" <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />e ► ej • rr� - '10 : rr, C•, <br />