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Pleisii!3* or type. (Form designed for use on elite (12-oftich) tVDSWiriter.) <br />1111 Form Anaroved. OMB No. 2050a39 <br />EPA Form 5700.22 (Rev. 305) Previous editions are obsolete 13,70 1 C 1! -i'l It TO C. _--K 8'WE (iF U 1! 1;- 1 <br />UNIFORM HAZARDOUS <br />I Generator ID Number <br />2. page I of <br />3, Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />I I <br />I --11_- <br />1 008548588 FLE <br />5. Generators Name and Mailing Ad&93'--"'- Geriarati Site Add7rets'(if different than mailing address) <br />')J1. 1'52rt:,;­:-A <br />111MNL <br />Generator's Phone ir% rhr, <br />6, Transporter 1 Company Name <br />-Tran <br />7. Transport2 M4_Wnfti7V b3:-!--' <br />8. Designated Facility Name and Site Address US, EPA ID Number <br />'auJl 0 1" 7T1 V J -6 11 D 2 rl"- 71 <br />- 1. 1. <br />Facilit)lsftne: <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />0 <br />9 <br />!J'!'j ?50, lij a t' P a ".1 1 -2 <br />b <br />rj <br />j.31 <br />�Q'711 <br />Z <br />LU <br />C ti i -I- LA c e- t 'C i^: <br />J 9:. <br />P1 -a d lict <br />4. <br />14. Special Handling Instructions and Additional Information <br />2. 11.7.- 3 3i..0 1, - a i I i c: - f L, C v !-I <br />'L -7"e40.4 11-34 G1110 <br />15 GEN ERATOR'SIOIFFEROR'S CERTIFICATION: I hereby declare that the contents of ft innsigraom Ora fullyar.d amrsoily described above by the proper moping um, and afe classililled, packaged, <br />marked and latielediplacarded, and are in all respects in proper condition for transport acuoiamg to applimilbie jnWmknW and nst[anaii gaywrimlinl1iii regulalion& Ifexport shitinnd and I om the Prinary <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 a small quantity generator) is true, <br />TeneratoPORW7Z Prin WMName gnature Month Day Year <br />_j <br />F_ <br />16 Intematronal Shipments <br />0 Import to U.S. 'PUR6119'ntlYleXil: <br />Z <br />Transporter signature [for exports onlv-).:- Oate, leaving U.S.: <br />17_ TransporterAcknowledgment of Receipt of Materials <br />Transporter I PrintediTyped Name Signature r r onth Day year <br />CL <br />Trftpbrter'2 PrintairrryoddName Signature Mow Uay- -Year <br />Discrepancy <br />I18 <br />18a. Discrepancy Indication Space L a.mily Type ❑Residue ❑Partial Rejection ElFull Rejection <br />Manifest Reference Number. <br />18b.Allernate Facility (or Generator) U.S. EPA ID Number <br />LL <br />Facility's Phone: <br />LU <br />186. Signature of Alternate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Repoh Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />2. <br />�3, <br />I4. <br />20. Designated Facility Owner or Operator: CortificatioAci receipt of hazardous materials covered by the manifest except . as Zd in item 18a <br />PrintedfYyper! Name Signature Month Day Year <br />( )(V (.1 <br />EPA Form 5700.22 (Rev. 305) Previous editions are obsolete 13,70 1 C 1! -i'l It TO C. _--K 8'WE (iF U 1! 1;- 1 <br />