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cit or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 00kiWARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJK WASTE NIFEST - 5. Generator's Name and Mailing Address Generator's Site Address (f different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HM and Packing Group (9 any)) No. Type Quantity Wt.Nol. O Z 2: f LLJ 3. 4. 14. Special Handling Instructions and Additional Information 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, packaged, 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 EPAAcknowledgment of Consent. 1 certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generatoes/Offeroes Printed/Typed Name Signature Month, Day Year. J 16. International Shipments import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials j2 Transportei 1,Printedffyped Name Signature r gMonth Day Year O_ QTransporter 2 PdntedfTyped Name Signature Month Day Year 18, Discrepancy 18a. _Q�antityty_ __DType Discrepancy Indication Space QResidue _ _0 Partial Rejection ___ __ _ ElFull-R jection _. _ ._ o _; __ _ _ Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number rcI � Facility's Phone: � i� L 003 LO 18c. Signature of Alternate Facility (or Generator) Month Day Year Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardo4s waste treatment, disposal, and recycling systems) W 1 _ 2:. m 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prmted(fyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. '' DESIG'NATED FACILITY TO GENERATOR