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,. .. Please print or type. Form Approved. OMB No. 20500039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency R sponse Phone 4 <br /> na <br /> meslTr cking ��- dNumber� ° ` JJ5. Generators Name and Mailing Address Genertors Site Address (If dlgerenl than maltg address) <br /> a <br /> . 1 Ir ix ' i 1inlli8i /tt: x !) I 1° JhV N':`N <br /> tl ul ll 11 'if(9 r F .a ;, (I >�a, 3 e N <br /> Generator's Phone;; <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> . ,t-AL, ? I N:a G'i1..lt rtt ?f ° , it,i'. . 11 n4+_:. <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> t-r :i i- t I 1 Yin0its. iV f,41 t I �Alq 1 ItI'it Tt: t SlituI 10�`;lU. <br /> 8. Designated Facility Name andSiteAddress - U.S. EPA ID Number <br /> Y t . t r,T, 6- ,4 ,t -. <br /> I i VIA if r t S , "'t <br /> Facility's Phone yy:_': c� :.,w a�wit <br /> ga 91h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)). No. Type Quantity WWoI. <br /> 1 <br /> K )t "ev U 11;1lI It lta' <br /> itdi . .t, . ,t:al P ' , rpstr .kl_# 9 ii ll(' gVf.lA Iu_ <br /> 1 ' Jq . <br /> Z 2. <br /> W <br /> 12 __ . <br /> 3. <br /> 4. <br /> 14, Special Handling Instructions and Additional Information _ <br /> � , r r , sir , 3,+ :n <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, are 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 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 comity that the waste minimization statement identified In 40 CFR 262.27ho (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br /> G n r toeslOfleroes PrintedfTyped Name + Signature _ t Months pay, Year <br /> 16. International Shipments ❑ Impo{t to U.S.i— ❑ Export from U.S. Port of antrylexll: <br /> ? Transporter signature (for exports only): Date leaving U.S.: <br /> o_ 17 TransporterAcknowledgmenl of Receipt of Materials <br /> Tranbporte� PrinledlTyped Name t Signature Month Day Year <br /> a ,- rt` < 7 � 0 id <br /> a Tran;P r1 I Pnnl d yp d Name �' S,'IgnaluP 7 , _,x l M ih Dpy <br /> Year <br /> a' Jd i f ,y <br /> 18, Discrepancy <br /> ran. Discrepancy Indications ace ❑ Quantity - -- - ❑ Type M3❑ni(Re idue Reference Number. ❑ j - - ❑ Full Rejection <br /> P Residue _ Partial Reeciion <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> u Facility's Phone: <br /> w <br /> 18c Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (Le„ codes for hazardous waste treatment, disposal, and recycling systems) <br /> I . 2. 3. 4. <br /> 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as raced in Item 183 <br /> signature, Month Day Year <br /> Pnn� d/Typed Name t ; <br /> EPA Form <br /> ol/8700-22 (Rev. 12-17) Previous editions are obsolete, / DESIGNATED jFACUTYa OGENER GENERATOR <br /> i <br />