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1[ <br />Please print or type. (Form designed for use on elite (12-pitchl typewrRer.) <br />Form Approved. OMB No. 2050-0039 <br />} UNIFORM HAZARDOUS 1. Generator lD Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST 1 <br />JJK <br />5. Generades Name and Mailing Address Generator's Site Address (If different than ma ting address) <br />Generator's Phone <br />6. Transporter 1 Company Name 115. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />6. Designated Fa,! ry Same ani Site At dress U.S. EPA ID Number <br />Fzdlityrs Phone: C AT 000646 1 9 7 <br />93 <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />H,,, <br />and Packing Group (a any)) <br />Quantity <br />Wtvol. <br />O <br />F - <br />Q <br />K <br />2 <br />2 E�p$ 4 „%F t era <br />AUG 0 2 2016 <br />ENVIRUNMi <br />HEALTH DFFIAiRTAAENT <br />1. Special Handling Instructions and Additional Information <br />et,to.._Er a;il�11�,T', eO@lBYY,L., <br />2a ttii NCI' C'ON'TACT' E#dWP OSEIl2r <br />15. 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, and are classified, packagec, <br />marked and Iabe:edlplaarded, and are in all respects In proper condition for transport according to applicable intemationaland national governmental regulations. if export shipment and I am the Prima' <br />Exporter, I mildly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I of that the waste minimization statement identified In 40 CFR 2611111 am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generalor'slOfferors Printedrryped Name Signature Month Day Year <br />F <br />16 International Shipments <br />El Import to U.S. ❑Export tom US. Pon of entrylexit. <br />Transporter signature (forexports only): Date leaving U.S : <br />w <br />17. TransporlerAcknowledgment of Rai of Materials <br />Transporter 1 Printeei Name Signature Month Day Year <br />O <br />a <br />co <br />4 <br />Transporter 2PdnteGRyped Name Signature Mont Day Year <br />K <br />H <br />18 Discrepancy <br />18a. D'auepancy Indiafion Space ❑Quantity Ll Type ❑ Residue ❑Partial Rejection ❑Full ReieCuon <br />Mandest Relerence Number. <br />r <br />18b. Alternate Fal lhy(or Generator) U.S. EPA IDNumber <br />Zi <br />U <br />I <br />Fadgty's Phone: <br />w <br />1Be. Signature of Alternate Facility(or Generator) <br />Month Day Yea, <br />Q <br />Z <br />1. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3 <br />4. <br />:JtO <br />Deal arid Facility Omer or Operator: Certification of receipt of hazardous materials covered by the mani(estexcept as noted m Item 18a <br />md1r Name Signature y Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERA <br />