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Please print or type. Form Approved.OMB No.205HO39 <br /> t 11UNIFORM lfAZARptalfS �'Generator IG Number 2.Page 1 of I Emergency Response Phone 4.Mantfast Tracking Humber <br /> WA fuFANIFEST "Ai r iF rr';i!;;{+.; }{t y:yf!-� ',It.. .ctip 1 0-22�` JJ <br /> 5.Generators Name and Mailing Address ;� Generators SmAddress{ff different than coaling address) <br /> 517!?t Fdltpm "tnffl 1 <br /> ,.!i ii: <br /> 7-4 f`':.j}`le+1 <br /> 3tf�j tit+;fl1 <br /> Generators Phone- <br /> 6 <br /> hone: <br /> 6-Transporter 1 Company Name U.S.EPA ID!Number <br /> r.ir-.r.. r;•ro.. o .}nt. <br /> 7.Transporter 2 Company Name ; <br /> U.S.EPA ID Number <br /> 8,Deaigstated Facility Name and Site Address <br /> U.S.EPAID Humber <br /> Fadtiys Phone: <br /> ga. 9b.U.S.OOT Deacripbon(induding Proper Shipping Name,Hazard Class,ID Number, 18.Containers 11,Total 12.Unit <br /> y[y and Padang Group(if any)) No. Type Quantity mml, 13.Waste Codes <br /> t, <br /> !Y � <br /> Z 2. <br /> I <br /> I <br /> 3. s <br /> 4, <br /> I4.Special Handling Instructions and Additional linformadon <br /> • t•,,r,�t... r�=,..:�'�;,rs t.p r• - f_,s�is i''rcatir�i�at'�_i15,r l:t+rs�r raa�,r•_�rt��?��'l?#i;lua�Fir�rus::r, <br /> s , <br /> 11 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dodare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemafional and nadenal governmental regulations,If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cwto m to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement iden5ed in 40 CFR 262.27(a)(If I am a large quay tyge'nerator)or(1 {ifl am a s"JLquantity generator)is true, <br /> GeneratcrslOffemr4 Printed/Typed Name S grma,re / f' Month Day Year <br /> -j 16.Intemational'shipments �~ <br /> r.. ❑Import to U-S. ❑Export from U-S- Port of enlrylexlt r` <br /> ? Transporter signature(for exports only): Date leaving U.S.; <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pr nlediTyped Hama ' Signature .i ; Ma, Day Year <br /> p _�3 � t , <br /> a- ' xr"y.. r. it 1�" u G.y1" mow•• .. r _ ..r.-^.�„-,4 •' '"1 f <br /> 2 Transportar 2 PdntedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 16a.Discrepancy indication Space ❑ Ruantil ❑Type ❑Residue <br /> Y ❑Partlal Ra)ecloon ❑Full Rejection <br /> Manifest Reference Number- <br /> F— 18h,Alternate Facility(or Generator) US.EPA ID Number <br /> V <br /> LL. Facility's Phone: <br /> U0 I k Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 79,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> y t <br /> 20,Designate Facility Owner or Ope*or:Certification of reoelpt of hazardous materials covered by the manifest except as noted in ltem•18a <br /> PrintedrTyfEDEame Signature - � _. Month Day Year <br /> EPA Form 8700.22 Rev,1247] Previous edltiodare obsolete. - TRANSPORTER COPY <br /> �.._.._- <br />