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Please os'�I ctatvoe. (Form desioned for use on elite (12 -Pitch) tvoewriter.)11
<br />OFF
<br />Farm Approved. OMB No. 2050-0039
<br />EPA Form 8100-22 (Rev. 3-05) Prevfotiy
<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number
<br />2. Page 1 of
<br />3. Emergency Response Phone
<br />11
<br />4, Manifast Tracking Number
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<br />5. Generator's Name and Mailing Address Generators Site Address(if different than mailing address)
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<br />Generators Phone:
<br />_ _ U.S. AID Number,
<br />6.Tmnsporlor Ci ..r�tPanyName� ,. -�—� ,r P
<br />13 a
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />8. Designated F ( 8 e'aAdj rte dtJressy p , j,F' s U.S. EPA ID Number
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<br />Faclfity's Phone:
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<br />tib, U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number,
<br />10. Containers
<br />11, Total
<br />12. Unit
<br />13. Waste Codes
<br />HM
<br />and Packing Group (if any-))))
<br />No,
<br />Type
<br />Quantity
<br />Wt.Nol.
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<br />14 Spciai Handiin instructions a d ditional Information y y COM
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<br />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,
<br />marked and labeledfplacarded, 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 EPAAAnovrfedgment of Consent.
<br />I cenily that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is true.
<br />GeneratoeslOtferors ri edrTyped Nynme Signature Month Day Year
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<br />t.. C- r ��'�' ..�° .� ..��t
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<br />i6, international Shipments
<br />❑ Import to US. ❑ Export from U.S. Port of e t exjl` Y� ..... . ,...._. . ____ ..._.... __•..�.....___.,_
<br />Transporter signature (far exports only): Date leaging,U'S.:
<br />E4
<br />V. Transporter Aeknowiedgment of Receipt of Materials
<br />Trans prier 1 Printeciriyped t ame Signature Month Day Year
<br />1
<br />1
<br />zi
<br />T(dif porter 2 Printe ype8 Name Signature J /e) Month Day Year
<br />18. Discrepancy
<br />188, Discrepancy Indication Space n Quantity Type ❑ Residue rr--� ❑ Full Re
<br />t_J Partial Rejection lection
<br />Manifest Reference Number:
<br />i8b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />W
<br />Facility's Phone:
<br />w
<br />18c. Signature of Alternate Facility (or Generator)
<br />Month Day Year
<br />a
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<br />19. Hazardou4Waste fjepon Manpgement Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems)
<br />A
<br />1.2,
<br />3.
<br />4.
<br />JIFF1,
<br />20. Designated Facility Owner or Operator. Ce4ca8on of receipt of hazardous materials covered by the manifest except as noted inrRem 18a
<br />Printodrfyped Na IFSignature /} / Mdnth Day (ear)
<br />`
<br />di(ions ate obsolete.
<br />DESIGNATED FACILITY TO GENERATOR STATE"(IF REQUIRED)
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