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Please Vint of yoer (Form dasioned for use nn stile 117_nitrhl <br />EPA Form870022(Rev.305) Prevlouseditions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />Form Approved, OMB No. 2050-0)39 <br />UNirORM HAZARDOUS 1'� ID Number 2. Page 1 of 3. Emergency Raspmsa P,hora 0. Mani Trac u s <br />WASTE MANIFEST � '— "i � 3' 1 9 ii 3 i u � � , 14- 31- %�j � d 13 JJK <br />5. Generator's Nzrtw arC MagNg Address J GeneraZes Site Address (d diP.erent than marling address) <br />ti's: •K • . .. 4 wr <br />Generators Phdna`t�i•'r:�iti, .+:•i': may-;. <br />6. Transputer 1 Company Name <br />U.S. EPA ID Number <br />^ Q 010 l i 3 3 6 i <br />7. Transporter 2 Company Name <br />U.S. EPAID Number <br />6 Cesig; aced Faaflry Name and Sr'teAddress U.S. EPA ID Number <br />LiCY` <br />f' -Y "5y�..:k = 0 S t? 0 2 3 <br />Facility's Phonar _1� .? }' 2 1 i -0-J.5 w5 <br />gar <br />9b. U.S. DOT Description (including Proper Shipping `lame, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (d any)) <br />Quantity <br />'vytAm <br />f 3. Y1as a Codes <br />No. <br />Type <br />_..: 'L�.4Z ',- <br />�. ..-i; . tip <br />J fi i <br />= <br />t <br />Z <br />2. <br />LUt <br />I <br />i <br />4. <br />14. Spedal Handling Inshctiors and Additional Information <br />15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby cecla:-e that the contents of this consignment are." and accurately described above by Ine proper 3Npping name, and are classified, packaged, <br />marked and labe!edlplacanded, and are in all respects in proper conditlon for transport according to appfcable inlranadenal and natonal governmental regUations. If export shipment and I am lis Primary <br />FxpdRer, I certify that the contents of this constgr.ment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I Certify that'he waste minimization statement identified in e0 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is bce. <br />GeneratoesI.OAercisPdnteed/TypedNana Sig\ture Month Day year <br />C <br />i <br />IE. International Sfspments <br />ti to U S Export ham`kS� port <br />rm <br />V\_ of enlrylezit: <br />T ansporter s gnature (far exports orh!) Date leaving U.S. <br />W <br />17. Transporter Acknowledgment of Racwpt of Materials <br />Transporter t r ,Wffypfd Name Si urs <br />� r /! Signature Month Day 'ear <br />f . ,�'.' 'r- - �c•�� <br />ra <br />= .•:.-LTJ �.>< �- i' , . ^ � /7'�' � �.� � ..c:�? � �`c� <br />T ranspor;er 2 PrintedrTyped Name Signalwe ",lontn Jay `r=.ar <br />H <br />16. DiscrepaMy <br />'9a. Discreparvy indication Space quantity ❑ Type ❑ Ras'due Partial R%avirr; El : awl Rcjer'on <br />Maii°est Retererce Number <br />J_ <br />1Eb.Awnata Faahty (or Generato:l J S. cPA!D:,.t rter <br />V <br />auhtys Phone. <br />Alternate Facility (or Ce error) <br />QtEcSgnatueof <br />t:urth Jay r;rar <br />19. Nazanxus'A'aste Repan Managemert Method Ccdes (i.e.. xdes for hazardous waste trcatrrref. cisposal, and recyci,g systema) <br />G <br />1. <br />2. <br />3. <br />1. <br />,r�j� <br />i �[� <br />2C. Cesgrated Facility Owner orCparater. Certification of rocaiph of hazardo s natedars covered by the manifest except as need n ^em 1Ea <br />Pdrtedryp-aiwe i J Signature ticnlh Da "Nur <br />EPA Form870022(Rev.305) Prevlouseditions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />