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PlAam wint (w hma- (Farm daskrwd for use an alts (12-oftl Meamillar.1 <br />Form Approved. OMB Pb. 20500039 <br />EPA Form 870022 (Rev. 3-05) Previous eclitions are obodete. <br />GENERATOR'S INITIAL COPY <br />UWOM IWAFWA Generebr 1.11) NumberVW*W <br />2. Pop I of <br />3 . Emergency Response Phone <br />racking N unber <br />7003"14 <br />H JJK <br />WASTE MANFEST <br />. <br />0 %J Zi <br />5. Gerwaloft Nam and Mailling Address Generalloc's Site Address (6 df mwd than maillirg address) <br />'-l-T <br />6. Transporter 1 Company Name U.S. EPA 10 Number <br />7. Transporter 2 Company Nan* U.S. EPAID Number <br />8. Designalled F!!_ y Nam and Site Address U.S. EPA ID Number <br />A" <br />FwWs Phone: <br />9, <br />9b. U.S. DOT Descripboin (Including Proper Shipping Nam, Hazard Class, 0 Number. <br />10. CoMainers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />NO. <br />Type <br />HM <br />and Paddrig Group (if any)) <br />Quantity <br />Wt.A/d. <br />x(10. • '-i I <br />2. <br />Uj <br />3. <br />4, <br />114MMM111811dill <br />-- <br />15, GEMMTORWOFFOWn CERTilill I hereby dedwe that the conleollsofthis corWgrraent aro fullyand soolniallydeacribed above by the proper shipping name, and aMdBSSft, Packaged, <br />malted and laballed1placmded, and are in all respects in MW condition for transport soothing to applicable internsoonal and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I m* that the contents ol the oonsignmod wnlorm to the terms of the allached EPAA*wftdWnervt of consent. <br />I cw* that the waste n**nization slatoment idwMed in 40 CFR 262.27(m) Cd I am a large qAv* gerwe" or (b) (if I am a " Wentily generator) is true. <br />Garmawso fferoes Prinied/Typed Name swab- Month Day Year <br />16. kdernallional Shipments import to U.S. EExport tram us. Port of entry/ext <br />TWAPW- signature (for exports ordy): Dab leaving U.S.: <br />CC <br />17. TmnsporWA&noWM*AW d RBoapt of Materials <br />Twwporler 1 RWWyped Name Signall!" Month Day Year <br />PM*nyped Nan* $ig"ture month Day Yew <br />18. Marepancy <br />18e. Discrepancy Indication Space 1:1 Quantity EITYP F1 Residue ❑ Partial R*cbDn El Full Rejection <br />Man" Reference Number <br />lab. Allemate Facility (or Generator) U.S. EPA ID Number <br />F=W. Phone: <br />18e. Signature dMernalle Facility (or Generator) <br />Month Day Year <br />19. Hawdous Waste Report Managermt Mwhod Codas (i.e., coda for hazardous *90 K Weft disposal, and recyckV systems) <br />i91. <br />T- <br />1 3. -T <br />Designated Faak Owner or Operator: C&VCMM of MOW of hazardous MMWS covered by the r rem 18a <br />—Year <br />1120. <br />1 Prinieffyped Now SWAXV Mordh 5F <br />EPA Form 870022 (Rev. 3-05) Previous eclitions are obodete. <br />GENERATOR'S INITIAL COPY <br />