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(Fnrm dr-skinnid for usrt nn elite 112-nitchl Wnewriter.l Form Approved. OMB No. 2050-0039 <br />EPA Form - 8700-22 (Rev. 3-05) Previous Millions are obsolete. <br />DESIGNAT ED FACILffY TO GENERATOR <br />1, Generator ID Number <br />UNIFORM HAZARDOUS <br />HAL <br />2. Page I of <br />I _3Emergency Response Ph <br />4. Manifest T rackling Number <br />G B I <br />_4 <br />5, Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />7 li 10 8 L 4 V-3, 81 <br />Generator's Phone:,.-,, i- <br />6. Transporter I Company Name U.S. EPA ID Number <br />A,N,I!Li�RJGAN VAIiJ,F-.Y <br />Al <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />,0;5 131',Rli <br />Facility's Phone: <br />i <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12. Unit <br />I <br />13. Waste Codes <br />No. <br />I Type <br />HM <br />and Packing Group (if ani <br />Quantity <br />Wi <br />4. <br />'4. Special Handling Instructiong I- and Additional Information <br />('�"*tATAOIT; •31 li., <br />15, GENERAToR!S1OFFER0R`S CERTIFICATION: I hereby 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 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 i (if I am a small quantity generator) is true. <br />Generators/Offerors Pdrited/Typed Name Signature. <br />Month <br />Ye& <br />(V <br />�Dgy <br />_J <br />16, International Shipments------ <br />El Import to U.S. ❑ Export from U.S."­ Pod, of an ry/ex <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW <br />U <br />17, Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Prini Name oSignature <br />` <br />Month <br />Day, Year <br />CL <br />7 <br />1 <br />12, 1 <br />Z <br />Tra sporier 2 Printedrryped Name <br />Month <br />Day f-Yeaf <br />/61 <br />1e.161screpancy <br />18a, Discrepancy Indication Space ❑ Quantity 0 ❑Type Ll Residue Partial Rejection <br />❑Full <br />Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID'Number <br />rQi <br />FaclIty's. Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />Month- <br />Day Year <br />9. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials.coverdd by We mapilqill as noted in Item 18a <br />QdntWi Name gi <br />1,J <br />Month <br />Day Year <br />EPA Form - 8700-22 (Rev. 3-05) Previous Millions are obsolete. <br />DESIGNAT ED FACILffY TO GENERATOR <br />