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CJI Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manffest Tracking Number WASTE MANIFEST .;,, ;: JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 41'�I t-+.,Iht,•,L 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 She Address U.S.EPA ID Number Ri•,ilmpf;.a.�:tlr 4,?• ;�:,K'r' Facility's Phone: 9a 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(if any)) No. Type Quantity Wt.Nol. r0A. z 2. ; i L j•;ry'tlJv� VY4 - ` V Tr•�r I 3. 4. t 14.Special Handling Instructions and Additional Information mrd 17; 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 intemationaland nabonA 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(f I arp a small quantity generator)is true. Generators/Offeror's Printed/Typed Name Signature' ! r Month Day Year 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter4akIP'' ted/Type�djName Signature r Mogth Day Year QTransporter 2 Printed/Typed Name Signature Month Day Year rY t-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type E]Residue Partial Rejection Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ v uQ. Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY