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!"K f-3))]Tr 2311,1 PIES Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050.0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. G E N E R ATC) W S I H I T I A L COPY UNIFORM HAZARDOUS 1 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number14 C\1 WASTE MANIFEST 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) ;0 l6'd)r L [l! St 'I Arm Fit: Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number .;(1f•[ I v-.,1,IF.F.�a sY�:n�.rrs ):Pif: rxt��lt?►r��t�t��a�t.� 7. Transporter 2 Company Name U.S. EPA ID Number + i :lN Fdli42l3(.111;3 L-A:ri i;ONMIENML... SVC MA).)03931J-,,;F:``0 8. Designated Facility Name and Site Address�•I �,.�N HARBORS tif)1'� ,t(l; if U.S. EPA ID Number 10,}l bI---'RRY1 ,3.3A ROAD 11- fit Pt /:.rir; -4141. ')r',(.;B + Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt./Vol.13. '-`,(films NON-••ftt'M1 Ht)Zf)i,'L)0138 6vFSIC, o I1If2iAD9s (`;3ON1#4 TETIMAi]iiR'rt l Z 2. w (D i A ! I 3. `I l I 4. - � l I 14. Special Handling Instructions and Additional Information -14778769 9 FF1 ;.> l 1'1*j A )its J--M1--R13Fildi_ V Ill -4-1t�0-468.1760 mw 1 'rF X) r.tt I i'i i �'d•' rrlf,{..f,t I r .. I ;i 1•'f> t ,, 7 r.{-1+tc�t ?'� �,(I,i t ,I 11; ; ' ! I :f�- : ;::,; s ,zi'• r•, f' 15. GENERATOR'SIOFFEROR'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, marked and labelediplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. GeneratoeslOfferoes Printedfryped Name Signature Month Day Year F- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S, Pon of entrylexit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials W Transporter 1 Printed/Typed Name Signature Month Day Year O a Q Transporter 2 Printed/Typed Name Signature r Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Partial Rejection Full Rejection Manifest Reference Number: r 18b. Alternate Facility (or Generator) U.S. EPA ID Number U Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3 4. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prinledffyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. G E N E R ATC) W S I H I T I A L COPY