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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Aooraved. OMB No. 2050-0039 8700-22(Rev.a-ub) i rewousediaonsareobsolete. DESIGNATED FACILITY TO GENERATOR UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST - -- -- .:.--- I / JJK 5. Generators Name and Mailing Address GeneratorsSite Address (if different than nailing address) + IK Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name I U.S. EPA ID Number 1 -C S. Designated Facility Name and Site Address U.S. EPA ID Number UTA -v, AZ 66,%5 Facility's Phone: _. ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity WL/Vol. 13. Waste Codes No. Type L C 2 2. W 3. 4. 14. Special Handling Instructions and Additional Information ti,':a9 ;" i ,r I_i4 C:'vcS .�;t,,-arfr �.S`0C?cr`e g.;.,.. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacaided, 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 EPAAcknowledgmen��t Q4f�Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator);&, jiNam a small quantity generator) is true. Generators/Ogerors Pnntad/Typed Name Signa re/ Month Day Year y__ 14 J Z 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Pod of entry/exit: - Transporter signature (for exports only): Date leaving U.S.: w 17. TransporterAcknowledgmeM of Receipt of Materials Transporter 1,Vrinte¢Typed Name, Signature Month Day Year G Transporter 2 Pnoted(Typed Name ,V Signature 1'; t - Month Day Year ry Discrepancy t18. Its. Discrepancy Indication Space Quantity ❑Type ❑Residue ❑ Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility(or Generator) U.S. EPA IO Number J U LL Facility's Phone: ~ Maj 18c. Signature ofAltemate Facility(or Generator) Month Day Year Q 2 y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) p 1. 2. 3. 4. 20. Designated Fatalityer or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise Proved Typed Name 4 Signature Month Day Year ted! 8700-22(Rev.a-ub) i rewousediaonsareobsolete. DESIGNATED FACILITY TO GENERATOR