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Please print or type.(Form desgnodl 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.Man fast Tracking-568 JJK WASTE MANIFEST 613 4ff S.Generator's Name and Mailing Address Generators SIteAddress(d different than mailing address) Generator's Phone: 6.Transporter 1 Comparry Nan 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 FadIlly's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.cafth-M 11,TOW 12.Unit HM and Packing Group(if any)) No. Type QUM* wilivol. 13.Waste Codes 3� 001 too 4. r4.Special Handling Instructions and Additional Information 'VJ1.' r:"{u 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping naffle,and are classified,packaged, marked and labelad/placarded,and are In all respects In proper condition for transport according to applicable International and national govemm&,bl regulations.If export shipment and I am the Primary Exporter,I oe*that the contents of this consignment conform to the terms of the attached EPAAckriowiedgment of Consent I certify that the waste minimization statement identified In 4D CFR 262.27(s)Cif I am a large quantity generator)or(b)Of I am a small quantity generator)Is true. Ganerators/Offeror's Printed/Typed Nam, Signature Month Day Year =j 16.International Shipments I-- 1 1:1 Import to U.S. ❑Export f.U.S. Port of entry/exit: '3 Transporter signature(for exporta only); Date leaving U.S.: = L 17.TransporterAcknowledgment of Receipt of Materials U �2 Transpopr I Printed/typed yped Name Signature Month Day Year 0 Transporter 2 Prnted[Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Q..ntfty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Altemate Facility(or Generator) U.S.EPA 10 Number LL. Facility's Phone: Ch Uj 18c.Signature ofAitemate Facility(or Generator) Month Day Year - !;R Z 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment disposal,and recycling systems) LLJ I C3 2 3. 4. I . 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Kern 18a FTntedffyped Name Signature Month Da Year I I I I I y EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY