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til r'`1.J <br />.ate t 0 <br />yleail y i 9 i ° ) yP ) FormA roved, OMB No, 2050-0039 <br />print or type, Form designed for use on elite 12�pi.ch 1 ev+riter, PP <br />_ <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Trackl`n� Number CC <br />`3 FL <br />WA( MANIFEST ixA [ OL <br />5. Generatar's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />5. <br />pal t4 aluddon <br />S` <br />CAq <br />MV <br />Generator's Phone: 42%1WIM ail <br />6. Transporter 1 Companyacme " U.S. EPA ID Number CAR"M4 � <br />g <br />7. Transporter 2 Company Name U S. EPA ID Number <br />8, Designated Facility Name and Site Address U.S. EPA ID Number <br />Adx�.�'Qf ed Cho a Gal T M tf1 V4 ADW1200871 <br />633 RIM C <br />�'EtMh <br />MM 87107 <br />Faculty's Phone: M <br />ga• gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tolai 12, Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity W0101. <br />iNant RC.Rid 7,ordaut3'1r'Va*:Ate:$Otqd <br />10 <br />2. <br />J)J <br />3. <br />{ <br />4 <br />14, Special Handling Instructions and Additional Information <br />1 X•B S4 11', &C l t'13NO T OA- 207 <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 iabetedtpiacarded, and aro In all respects in proper condition for transport according to applicable international and national governmental regulations, If export shipment and I am Ute Primary <br />Exporter,. i certify that the contents or this consignment conform to the terms of the attached EPAAcknosvfedgment of Consent. <br />I certify that the was(einWmfzafioh statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (R(if I am apall quantity generator) is true. <br />Genetalor s!_D ferors FrintedlTyped Nama gna ure; ) rMonthyaa( <br />Illre &O I 'WJAt tri .. '. �r fit% <br />M <br />16. International Shipments r�}{ <br />Import to U.S. Export from U,S. f Port of enirylexiC <br />-j <br />z <br />Transporter signature(for exports only): Dole leaving U.S.: <br />17. Transporter Acknowledgment of Racal t of Materials4 f j <br />Tra sp fief Pd a xyped Name i na a „yy ea <br />Cly, <br />z�L <br />Transporter 2 Printe rryped Name Signature + Month Day Year <br />18. Discrepancy <br />����II <br />t.8a. Discrepancy Igdication Spaco .� Quantity a LVI Type l f Residue __ .. .. L_J ParliaLRejecBan... t 1 Full Rejection <br />Manifest Reference Number, <br />18b. Alternate Facility (or Generator) US. Emu Number <br />v <br />I <br />'s <br />w <br />,a <br />Facitf Phone: <br />t8c'n afure o(Alternale Facility (or Generator) Month Day Year <br />z <br />vi19. <br />Hazardous Waste Report Management Method Codes (f.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 1 2. 3, 4. <br />20 Designated Facility OG+mer or Operator: Ceolipation of receipt of hazardous materials covered by Ste manifest except as noted in I(gn t8a <br />re r Month Day Year <br />Signature <br />Printed/Typed Name 7 ✓ 1f <br />` <br />EPA Form 8700.22 (Rev. 3.051 Previous edilions are obsolete. < DESIGNATED FACILITY TO GENERATOR <br />,.q <br />