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Please print or type. (Form designed for use on elite (12 -pitch) fvpewriter.) <br />Fnrm Annrnund r1MR Nn 9nFn-nnao <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 />Al. Manifest Number <br />WASTE MANIFEST <br />rt,pf;'r�rq"1` <br />�' <br />rn ' r <br />7V; •'t F L E_ <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Max,'1Kefi�bthcGttA Sii3£bltia>dD.,;`►�tt,v 11C4191-TIN..tYxAt'er C4. Attil 4: C41w–rd .fie 41tw 1 <br />St wAim-1, GA96^ <br />Generatofs Phare: <br />Transporter Company Nameee U.S. EPA ID Number <br />Ap1weU Ggm,r,Ui�oCkc, (AlkAli, +AZr61{�jy [•y,���y, ,� <br />4 K.�i i�1L Mf'+.►¢ <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />I <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />,d'4#i9"fraW C flhT.'1fli G1 li1Wrtriiont <br />�i�11'i 1%va n°z�rzl�!itlYi ` 1k'Py�B` <br />1 t <br />w tlt.�0, 6tiMtV1rid' <br />Facility's Phone:M•+3`4940.2 i <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 />, 0 d Pac ing Group (if any)) <br />Quantity <br />Wt./Vol. <br />13. Waste Codes <br />No. <br />Type <br />•.Pa 1 l.'?ls;.., .ae;W flolov, 3, ''iy 1:�4klil¢ <br />Dill"' <br />Z <br />2. <br />W <br />t9 <br />3. <br />4. <br />t <br />EP <br />8 201 <br />14. Special Handling Instructions and Additional Information <br />ENVIRONMENTAL <br />s ,. <br />(SJI L <br />15. GENERATOR'SlOFFEROR'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 govemmental 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 />en rat 5! erorsPrmte ype . ame nature _ on r <br />SSS <br />16. Intern tionat Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pori of entry/exit: <br />— <br />Transporter signature for exports only): Date leaving US.: <br />W <br />17. Transporter Acknowledgment of Receipt ofM terials <br />11- <br />O <br />Mo r 1 in tf y ed Name <br />ur of Year <br /><• <br />Q <br />Transporter 2 Printed/Typed Name Signawre Monthay ear <br />18. Discrepancy <br />18a. Discrepancy Indication Space' ❑ ,Quantity ❑ Type ❑ Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA I D Number <br />CJ <br />Facility's Phone: <br />LU <br />18c. Signature of Allernate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />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 />Ll20. <br />Printed/Typed Name I Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />