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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Annroved OMR Nn 2nsn-nnmd <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />0 � ' t'�i` ;,9 LJ � <br />FSE <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Generators Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WI.NoI. <br />13. Waste Codes <br />No. <br />Type <br />1' <br />0 <br />'..'i1I ,'i'�Y!tl; .'r1-. Pt; -1 It •'�.. .1. <br />I ..-_- <br />..-.. -.... <br />l <br />w <br />Z <br />2. <br />LU <br />),Its! , i�t�:;►IE f E011utMlFi#s1-! b.1(1,tt3i`>.'i,F.I.�J.!i., �t'�t:.E.'i(1A!: <br />_.. <br />.. _.... <br />Myt [.1101, KBROU-1. 3, Ki 11 <br />' <br />t <br />3.Y'iAI;R <br />i.()1M)`iJIVI HOW. SNt. 4$O1`t01wo., <br />'?.i A �'i.. Po:iC3l.yill.)i�,9 #1°!d1#ftt!1f,€�'.'it!! Nih,� F4'V1'{ w:111Ct9?111.1 i?. r•y!a <br />' {'' <br />I <br />4. <br />i <br />.12? 4, Wtdl{.IIi41}i E�A3riEVf' #.35;1}iYa,A14.: 81.?I r_, 111`44)ihi.iAth <br /># <br />i tl +; . (f.>1 fir :A t.! it. ":f14 I s. ►•t9r Atli, ) I. V ,, 11 <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'S/OFFEROR'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 <br />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 (b) (if I am a small quantity generator) is true. <br />riSignature <br />ay earGenerators/Oferors <br />l <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />- <br />Transporter signature for exports cnl : Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature <br />Month Day Year <br />0 <br />Q <br />Transporter 2 PdntedrTyped Name Signature <br />Month Day Year <br />1- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />a <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />Fn Fn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />'''•' <br />0 <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />ted/Typed Name Signature <br />Month Day Year <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />