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Pltlase print or type. (Form designed for use on elite (12 -pitch) typewriter,) <br />Form Appmved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. M5)'Previous editions are obsolete. - — DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS j1-GQ-0rDN""i` <br />IPepe I of <br />3t- &7977: ""7777�, <br />est Tredift lifistiber <br />14. Mfl 28 14 4 <br />Mn Pi <br />- <br />-11 JJK <br />5. Generator's Name and NW,N Address Genvatofs ItoAddress(K diffei m 4 than coaling address) <br />14:f o;4. r <br />CwWaices Phone: -3 <br />8. Transporter I Company Norm U.S. EPA ID Nwdw <br />7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />& De Ill 01'Faddy Nemo; Adrlro» U.S. EPA 10 Number <br />I31M <br />Fad"Raw, 2". <br />93. <br />9b. U.S: IDOT Desorliption (mcluding Prow Stinppitg Name, Hazard Cissa, ID Number, <br />10, Containers <br />11, Total <br />12. LWA <br />13. Weds Codes <br />NO. <br />Type <br />HM <br />and Pang Q -P (11 any)) <br />Quentilty <br />WILAW. <br />W <br />p I. <br />3. <br />14. Spoc# ".ing Insindons and Additional Information HEA' <br />15. GEKMMW3MFFER0R'S CERTIFICATION: I hereby declare that the contents of ft cow4nmanl are fully and accurately described above by the PMW SNWN "M, and are classified. packaged, <br />marked and labeWiplacarded, and are in all respects in proper condition for barvsp amording to applicable international and national governmental reguW&m H export ship wt and I am the Primary <br />Exporlar, I oW4 that the contents of #w consignment confom to the terms of the aftolled FPAAcknftWpeM of Consent <br />I crtly that the waste minimb2fion statement MwdW in 40 CFR 262-27(a) (If I am a large quantify generator) OT (b) (if I am a small quantity gerwatof) i3 Wse- <br />Generifted0hror's ftladfly* Nam Signature Month Day year <br />-j <br />16. tnternational Shipmentsr-1Import tDU.S ❑ Ewd from U.S. Port of entrylaxit <br />Transporter NWU[h- (for exports Only): Date" U.S.: <br />W <br />L U <br />17. Tiransponar Aclawmladgmord of Receipt of Materials <br />Transporter I PrimodVTyped Name Signature Month Day You <br />^ ^ <br />Transporter 2 PdrbdlTy* Name Signature Month Day Yar <br />18. Dismpancy <br />las. Discrepancy IndicoW Spam E] Quo("❑ Type El R.O. ElPartial Rejection ❑ Full R.).Oon <br />Manifest Reference Numoer <br />10b. Memate Focifilty (or Generator) U.S. EM ID NmAw <br />FacillysPhne: <br />18c. Signature of Alternate Facility (or C—tor) <br />Month Day Year <br />0 <br />;S <br />19. Hazardous Waste Report Management Method Codes (.e., codes br huarftz waste trestrnect disposal, mid mcydN systems) <br />Uj <br />k 1 <br />Lk <br />2. <br />I &yz <br />T 1 <br />4. <br />20. Desomied Fao* Omer or Opeptor Certification of mW of hazardous majonals ooywW by IN manifest except as noted in fitm 1 go <br />th Day Year <br />'R*Vyped Name signature' ; <br />7 a-19 �- <br />EPA Form 8700-22 (Rev. M5)'Previous editions are obsolete. - — DESIGNATED FACILITY TO GENERATOR <br />