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PlAase print or tuna. (Form rip finned fpr use nn elite 112•nitchl tvnewrfter.) <br />Form Aoarored. OMB No. 20SM039 <br />EPA Form 3700.22 (Rev. 3-05) Previous editons are oosolele. <br />i - DESIGNATED FACILITY fU UEyEHAIUtt <br />U <br />UNIFORM HAZARDOUS <br />1. Generator !D Number <br />2. Page 1 of <br />3" Emergency Response Phare <br />4. MaNtest Troeking um of <br />WASTE MANIFEST <br />.p ice` , ,r 3 JJK <br />5. Generator's Name and Mailing Address Generator's SiteAddress (if dibrent Ittan melting a(kress) <br />9.5204 'f)`.7': 464-664 <br />Genaraor's Phorte: <br />6. Trarsponar 1 Company Name U.S. EPA ID Number <br />ALL 7r,?te,��� !rT�t�ti''1j�1� 3 � ? A ;_. 0 7 r0 2 5 a 3� 1 <br />'l•3.Li X41 • a"k-.. �'2� <br />7. Trarsporter 2 Company Name U.S. EPA i0 Number <br />_itia1N, <br />9. Designated Fabtity Name and Site Address U.S. EPA ID Number <br />INDUST RIALT SERY ME CIL <br />iT.NO S. `FOTO ST. _ zk 7 a 9 A j 2 ° '0 i <br />7 r �'S ;AN `= f_.,' -c_ -- <br />Facditys, honer.:=: •_ . �,�..�a - � i. <br />9a <br />9b. U.S. DOT Description (ncluding Prcper Shipp ng Name.. Hazard Class, 0 Nurrher, <br />10. ar. a pars <br />11. Total <br />12. Un <br />13. Waste Codes <br />Nc. <br />Type <br />HN <br />and Packing Group (it any)) <br />Ouanfity <br />WtNol.it <br />1. ., .. <br />A.51 E <br />x:'':zRigZ1Y.1�tj-M <br />a <br />2. <br />w <br />I <br />3. <br />I <br />4. <br />t <br />It Special Handling Inshuictions arid Additional nformahon <br />DIR TER.: Us .._- <br />16. GENERATOW31OFFEROR'S CERTIFICATION: I hereby declare that the contents of stis consi7mert are fury erd accurately dowted above by the proper stripping name, and are class:tfed, packaged, <br />narked and labeledr'p'acarded, and are in all respects ;n proper cordltion for transport according o applicatis imematicnat and nadena govsmmentai regulatars..f export shipment and I am the Primary <br />Experter, ! certify that the coder of Cls rr ns gmnent ccnfcrm to tie terns cf the attached EPAAGmaMedgmant of Consent <br />I cedlfy that the waste minimization statement'dentifed in 40 CFR 26227(a) ('f I am a large quantty generator) or ;b) (`I am a smai quantity gverator) is he. <br />Gererzto'slOfferot's.RrinteNTyped Name S_oature Month Day Year <br />J <br />16. intarnawral Shipments <br />❑ Import to U.S. <br />�. <br />2 <br />7,3nsportar slgnat'ure (fcr exports only): Dai 'eaving U.S. <br />W <br />17. TransoorterAcimmedgment of Receipt of Matedals <br />Trarsportar 1 PFNad/TypedNama S.9r - ., F j Mto^tn Day Year <br />'Cay" <br />= <br />aac <br />Transpoift 2 PrintedrTyped \ame v Signature `:tenth Year <br />18.:isc.warxy <br />8a. C sc aparcy !rd:ca[cn Space C �e _ Res dLe - Partial Re,ac,= _ FA Re)eC on <br />uanety <br />','zri:est Reference N:.mber. <br />13b. 1%remata =a^.aiy ;cr Ger eretcr) 13. EFA iD Nr_ i <br />J <br />U <br />LL <br />Fad:itys Phone: <br />13r.. Sgratue cf Aterraa Fac At ;cr;,e^erdv) <br />Ycndt Day Yo_ar <br />Q <br />2 <br />y' <br />9. Huardcus'Naste Remr..:taragemsnt Me^ed Cocos (l.e., codes for hazzrda:s ease yea'urom, d'.spcsal, and recydrg syskemsl <br />C <br />1. <br />2. <br />3. <br />4. <br />2C. Designed Fac Cry O%vner cr Cperstor (i of rete pt Of iazardcus ma'atals covered by the marirest 3xcapFas .naad n nem ? Be r <br />2rintedrTyped Na Q9 1 Ncnth Cay Year <br />EPA Form 3700.22 (Rev. 3-05) Previous editons are oosolele. <br />i - DESIGNATED FACILITY fU UEyEHAIUtt <br />U <br />