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Please orint or -.voo. (Form destined for use an — [a i 112-nitchl rvnpwritar I <br />C— A---1 /.RIO Mn lil— — <br />FPA Form 8700-22 (Rev. 3-35) Previoui editbris are obsolete. TRANSPORTER'S COPY <br />U NIFORM HAZARDOUS <br />1.Generator 'a N"o'bef <br />zPage llof <br />3. Emergency Rowse Phone <br />4. Manifest hacking Number <br />-WASTE MANIFEST <br />JJ K <br />Ganicatca's Site Address (K different than mailing address, <br />7 <br />Generators Phiorie: q 4 i, <br />6. Transporter I Company Name U.S. EPA ID Number <br />1. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facii1yr Name and Site Address U.S. MAID Number <br />F3dlil 's Phorie: <br />ga, <br />9b. U.S. DOT esi:Wn jincluzing ProparShiiiping Marne, Hazard Class, ID Number, <br />10. Containars <br />11. rctal <br />12. Unit <br />HM <br />and Reeking Group (if any)) <br />Quantity <br />WLJVoI. <br />13. Waste Codes <br />No. <br />Ty%to <br />0 <br />3. <br />4. <br />14. Spedal.Lianding Instrucdorks andAddillional Intimation <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that to Lviterts of this oonsignment are fUly and accurately aescrted above by [he ' proper shipping name, and are classified, packaged, <br />marked and laWedliplacarded, and are in all respects In proper condition for transport according to applicade.ritarriadcrial and nationalgiavemmental regu%licirm. If export shipment and ! am :P.o Primary <br />Exporter. I owtify that the Contents of the cor&4nmentcorforrn to the !vrms of the attached EPAAcknow'eCgmentcfCcnsv.L <br />I certify trot the wa.i!a minimization statement idertifed in 40 CFR 262.27(@) (d I am a large quantity generator) or (b) (i(J am a small qwnfity generator) is true. <br />Gone WvOffeWs Prmted lTypeed Nam Sqnature, Menth Day ;ear <br />re <br />-J <br />1. <br />6international Shipments <br />ED Impert b U.S. IEXoalfruiiU.S. Port of enuyi"t ------- <br />Transporter signature (for expens cniy): Ode lei U.S.; <br />iX <br />LU <br />17 TransportarAckno~entof Receipt cl Maleiials <br />ransportef 1 PtVadiTyped Name S gnalurree Writh. Day Year <br />0 <br />CL <br />rrarsporler i Pririloct Name S.griatura Month Day Y.- <br />16 Discrepancy <br />Ift 06"Wasicy Indication Space Lf Type ❑ ❑ <br />Residue Pe'dal Rejection Lu Re,ect do <br />of, fcncq Number. <br />U.S. EEPA 10 NLmber <br />Phone: <br />Mi.A:h Cay Year <br />t9. Hazarw u'ftasie Report Manage rent Meted Codes (i.e.. cedes fcrhazardcuswaste treat.,vant IW-sw, and a fc4rg ;jstvrs) <br />4. <br />20. Des;gnakd Fxdity Owner cr Ciperalor. Codification of receipt J)azjrec4is maW.3Iszcveed by th.orrunifiest axcaot as rood in item 18a <br />Printeafryped Nam Signature Math Day year <br />Ll <br />'4 <br />1141 <br />FPA Form 8700-22 (Rev. 3-35) Previoui editbris are obsolete. TRANSPORTER'S COPY <br />