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0 0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM <br /> IFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackingNumber <br /> WASTE MANIFEST <br /> ('A(- 002192420 JJK <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Rqf'-H�t K;Nlkil�AWJ' <br /> Akf 1€.t0w tAmw4 *0'- M"'-' '0 1)K V 1 75 1`101'' <br /> I<45t 'Fx'1i s1 0" <br /> Generator's Phone: .2 -11 v <br /> 6.Transporter I Company Name U.S.EPA ID Number <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 /> 3,5,",! 01d,iX: <br /> R fAtkluum('I!. <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 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Niol. <br /> ac F�41%wRiallcowlty .1. ;c't I; <br /> 0 <br /> 2. <br /> LLI <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> P1411jr,' P' a�f A`K91"NM4 01 il <br /> Vtlt�m <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,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 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. <br /> Generator's/Offeror's Printed(Typed Name Signature Month Day Year <br /> 4<1 <br /> 1 ,2",5 1 C7 <br /> -j 16.Intemationall Shipments <br /> 0 Import to U.S. M Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space D Quantity ❑Type E]Residue 0 Partial Rejection D Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 0 <br /> 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPT® <br />