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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CMI 1371 - I 1 1 002182418 JJK <br /> 5.Generator's Name and Mailing Address Generator's — <br /> ZSAd <br /> ,.fress;(If different than mailing address) <br /> -100 Kadw Click NIS('1432 AVIN 1,61,1018& MI AW1 1 751 <br /> Prot W(w1b J'Y' 70 10 Slo,oAl-cwt ("A 91,20'� <br /> Generators Phone: RI ZAJ 11J2 <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> k— <br /> at: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Otftf. o-VIP M ftylage f,If"$it <br /> 3,5251 01-41 stylifil,Rlmd I I <br /> KWImt-wil 01y'k"A 93'1)"31) 9711 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 0 1JNVt7-!' WI rfr W911 I N, y <br /> -A with kmfi ,220 ptmj) <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PvAk 9-it)("AW1,80 144y 4)171 <br /> Wrwa Ntitm-i 1111- Mimi Jimw*ip Mak'm,4 <br /> 15. GENERATOR'SIOFFEROFVS 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the we*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. <br /> Generstoes/Offdroes Printed/Typed Name Signature Month Day Year <br /> -7 <br /> AI�E tz*T IL Q 112 <br /> -J -16-.Tn—temationai Shipments <br /> P- 'E1 import to U.S. ED Export from U.S. Port of entry/exit: <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> ce 17.TransporterAcknowledgment of Receipt of Materials <br /> UJ <br /> 12 Transporter 1 Printed/Typed Name0 <br /> Signatu Month Day Year <br /> 0 <br /> CL <br /> Transporter 2 PrInted[Typed Name Signature Month Day Year <br /> 18.'Discreponq <br /> 18a.Discrepancy Indication Space El Quantity 'EIType El Residue El Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> Facility',Phone: <br /> 0 1 8c.Signature of Alternate f7adlity,(or Generator) <br /> LLJ Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ <br /> 2. 3. 4. <br /> 20.-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedRyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />