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Please print or type. <br />P- A --i ohAp Ni, onrn nnza <br />LPA corm d[UU-22 (Kev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Ndmber <br />2. Pagel of <br />3. Emprqq�; y Response Phone <br />------ ---- <br />Man <br />Manifest Tracking Number <br />WASTE MANIFEST <br />58( <br />1 <br />J <br />1 -800- 19 S�-, Z <br />02035-6617 JJK- <br />5, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />R 08A DEA. rA IR <br />H, r I H i' 0 t4. I A, -i 10N <br />F*RENCH CAMP GA 952-'.il. <br />Generator's Phone: 09 - 9 8 3 - 2 4 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />,4er <br />`6 C fE' R I-,. C 0 V E R Y ',i f R V I C ff S , 2 5?. 405 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA!D Number <br />04�`XOVE.RY SFERV10ES <br />31-.)0 E'A'ST (-"iccl KV0 <br />I '"N6ELE'.3, cA goon <br />Facility's Phone: ( E300 ) 4199 -7 <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 />Wit./Vol. <br />13. Waste Codes <br />No. <br />type <br />0 <br />VJ FT 777, 1 1 t.. A J. fV1 1 H L. L. Irk I t. 1.1 M A i 171717174T n <br />V91 <br />1 <br />Q*yvll <br />Z <br />2;1 N I. V '00 V,IA E R Q <br />LU <br />om <br />I`4 FJ '3 A C l N E <br />o <br />P <br />1"A I F'. <br />14. Special Handling, Instructions and Additional Information <br />2 64e4?) 9b3) APO 6334 9b4)-"� ---4-9r' <br />6LOV-S, L--,06(,-iLES & PRO"FECTIVE CLOTHlNG 24HR EMERQVN(.,Y CONTACT, KTRK WALDORF <br />ERG#: 9bl) 128 962) 126 9t)3) 133 9,67T. -)-nn N E� J11111 111111111111111111111111111111 Ioll 1110 111) <br />T-", n n py --I� V7" 1 1 1- 1 o) 1" F, :t3-1-1.;348 I'm <br />15. GENERATOITSIOFFEROR'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 EPA Acknowledgment 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 />f7nerator's/Offeror`s Printed/Typed Name S atuT-- Month Day Year <br />_j <br />E- <br />16. International Shipments <br />i", 1:1 Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />iE <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />UJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />�4 <br />Z <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity El Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />:3 <br />0 <br />L<L <br />Facility's Phone: <br />0 <br />LU <br />18c. Signature of Alternate Facility (or Generator) <br />MonthDay Year <br />!R <br />Z <br />I I <br />0 <br />55 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, d' <br />osal, and recycling systems) <br />0 <br />1. <br />1 2. <br />3. <br />4. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />I20. <br />Printed/Typed Name Signature Month Day Year <br />LPA corm d[UU-22 (Kev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />