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, <br />4 'a <br />'WA t C <br />4.4 • - <br />, "4. <br />.44 <br />eso A* -4*4• <br />oril, <br />wit_ _At! <br />-10 <br />I •P v-e ' 4st it 'IP Arr 414 441. <br />I ,R <br />#Vir 1 .60' 46i 4at ea 44 *4- <br />a' * <br />'44 '44 ,44 •'4 ir '4 IA 44 4.4 "3* 44 vas "a4 <br />Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />Please printer type. (Form designed for use on elite (12-pitch) typewriter) <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />5 Ge,erotor's Name and Marling Address t <br />7 fOtA 2,37-V1) 043“A-iJ 6-itr 1117 <br />3 Emergency Response Phone <br />26 ' C/f5-41(() <br />14#3,21ty Address (if different than mailing addresk_i 7, 3-v oo, 12/1 <br />litA-eye Q 4- <br />1 Generator ID Number <br />Generator's Phone <br />2 Pa e 1 of <br />9b. US DOT Descnption (including Proper Shipping Name. Hazard Class. ID Number, <br />and Packing Group (if any)) <br />416 /0 14 <br />o 1 e-t <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arid 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if tam a large quantity generator) or (b) (if lam <br />es Printed/Typed Narne <br /> <br /> Signature — <br />4-A/ 441 5 /Ald2 <br />In emational Shipments D Import to U.S. <br />Transporter signature (for exports only): <br />Transporter Acknowledgment of Receipt of Materials <br />Transp r 1Rrinled/Typed Name <br />4frA/01/6 &5/ 6°' <br />T mower 2 Printed/Typed Name <br />18b. Alternate Facility (or Generator) <br />18c Signature of Alternate Facility (or Generator) <br />Port of entry/exit: <br />Date leaving U.S.: <br />19_ Hazardous Waste Report Management Method Codes (ie., codes for hazardous waste treatment, disposal, and recycling systems) <br />20 Designated Facility Owner or Operator Cerffication of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name <br />Signature <br />Form Approved. OMB No 2O55- <br />4. Manifest Trackin1Nrbi <br />00362 <br />376 GBF <br />1 <br />+. <br />8 Designated Facility Name and Site Address <br />14 Special Handling Instructions and Additional Information