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<br /> Please print or type,(Forr)designed for use on elite(12-pitch)typewitter.) • . Form Approved.OMB No.2060-0039 .
<br /> , .-- ,,,, uNiFoRm ifAzARnous '11.7eerator ID Number - , • 2.Page 1 of 3.Emergency Response Phone - 4,'Manifeet iraohing Number -
<br /> .t • WASTE MANIFEST ' C.11,6106 (1501/ .P ,,qW-71/ 5: 006321479 JJK
<br /> . 5,Generator's Name and
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<br /> denorator's Phone: c::NI tC;i.t.-si t 4.e-4")?t ' ' [ CAO•4111k 61- 273( (.0
<br /> U.S.EPA ID Number
<br /> 6.Transporter I Company Name .
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<br /> 7. itnsporter 2 mparly erne • .. . U.S.EPA ID Number.
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<br /> 8.Des Igeptfd Fadhty Namo and Site Addreta . U.S.EPA ID Number ' • ,
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<br /> . Faclfrnis Phone: 1.,f2,11,. f)N',, .7 pi.-X .
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<br /> , 91 Sb.U.S,DDT Description(inciuding Proper 6 hIppIng Nome,linzaid Class,ID Nuinber, 10.Containers 11,Total 12 Unit.
<br /> ,pi M .030 P1000 GrouP Of allY)) No: Type GualltllY WINek 13.1Naute Codes ,
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<br /> ( , 4.Splcial Handling Inslruclons.andAddi8onet Information • / .
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<br /> 16: GENERATOR'SIOFFEROR'S CERTIFICATION:I liereby declare that the contents OM coasts nen!are fully and accurately described above by the proper shipping name,and are(Ambled,packaged,
<br /> • marked and lab eledlplaca nfed,and am In all respects In proper condition for trensmni according to eppSceble Intern allonal and Ramat governmental regulations.If export ehipmentand I ern the Primary
<br /> Exporter,I certify that the contents of ills consignment cantorm to the'terms 011ie attached EPA Acknowledgment of Consent.
<br /> I eer*that Ole Wriate minOnizatIon statement Mailed In 40 OFR 262,27(u)Of I am a largetwank ge nerator)or(b)(if I ern a small quardity3gyra to r)Is true, •
<br /> Tienerator's/Offemr's Printed/Typed Name Signature .-7. . . Month Day Year
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<br /> 16.Intlfma anal Shipments or 7
<br /> Import to'U.S. El Exp rut from u.S I al of entryje-
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<br /> Transporter gnature(for Opts only): . Dale leaving US.: )3 ,/ '
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<br /> . i T.Trarisporlor 'atvivigrpent of.Racatpt of Materials ( /if PI- _,
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<br /> :..4= Transporter•Hilted/Ty]]-, erne Signs're. ! '41 ' Day Year
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<br /> ... 18,Discrepancy . . .
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<br /> 183.Discrepancy Indlcafon Space ri .
<br /> I-1()sadly [hypo El]Residue III Partial Rejection • 0 Full Rejection
<br /> Manifast Reference Number:
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<br /> 18b,Alternate Facility(or Generator) ' U.S.EPA ID Number ,
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<br /> La- Facillys Phone: [...—
<br /> e 180.Signature of Alternate Facility(or Generator) -----.7— Month Day • Year •
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<br /> -6 19.Hazardous Waste Report Management Method Cedes(I.e.,codas for hazardous waste treatment.disposal,end recycling systems) .
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<br /> 20.Designated Facility Owner or Operator:Dedication of receipt of hazardous materials covered by the manifest except as noted In Item Its ' -' .
<br /> Panted/Typed Nernee, Signature ,,.------''' ,,.71, , '. Month Day Year
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<br /> EPA Form 8700.22(Rev.3-05)Previous ad!'one are-obsolete. . ' e:OESIGTIAtE-b FACILITY TO GENERATOR
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