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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 I of 3.Emergency Response Phone [4:M—anifest Tracking Number WASTE MANIFEST I 1 1 002182444 JJK- 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) moik) 1 4 1 1 "St' 0 Ilivow,'�Jwc'k i 10-1 �4'0"J' 4(k' Generator's Phone: I Ar. 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number kettklfliiu k�A 431'�4�) VWQ--3441-9 Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes 1- R(A I 0 N ),8—9,1 RTV� 1'm; III, I fy CJ 3. 4. 14.Special Handling Instructions and Additional Information V, a)i 'A 00,�X41 01,11 wci�f e 15. GENERATORVOFFEROR'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. 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 smIll quantity generator)is true. GeneratorstOfferor's Printed/Typed Name Signature Day Year A C, CiA -j 16.International Shipments ❑import to U.S. 0 Export from U.S. Pon of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year 0 ZQ Transporter 2 Printedfryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Type Partial Rejection ❑Full Rejection Quantity F El Residue F Manifest Reference Number: g= 18b.Aftemate Facility(or Generator) U.S.EPA ID Number 63 Facility's Phone: LLI 18c.Signature of Alternate Facility(or Generator) -7nth Year 1 Day 1 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY