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Please print or type . Form Approved , OMB No. 2050-0039 UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST 6 2 4 18 18 JJ K 5. Generator's Name and Mailing Address 11iiCKftJN :iijrl:,', Generator's Site Address (if different than mailing address) �rti' ! 'kJ WX '277600 47:" $ . IHWY W MCNlfA3V: RD , 11 *AM: N I O , v; t t�tt:` i ; t ( x`KTC)N GA 957M Generator's Phone: 6 . Transporter 1 Company Name U.S. EPA ID Number MkH11C M VAJI- If 1' `VVAS I E 111111-. . IW & ;A€; 7 . Transporter 2 Company Name U.S. EPA ID Number WirteLiilrYlL)E• lilt (:iaVl FtY IdYSIFM.RA4F t ;AR(K10176422 8. Designated Facility Name and Site Address U.S. EPA ID Number 0,x11 t1b n i iil i 411WAY lXj Facility's Phone: ga 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit HM and Packing Group (if any)) 13. Waste Codes No. Type Quantity Wt.Nol. 1 . ) '' *4 Ht : i�AHAYAklXAL�* WA!:VF ':%N 1111 ) Af F*( WRFN1w8 PAPFR ( At I . . . _ .. . _ . . - . it 1Ff2 R E3(2tc; z 21 LU c7 3. 4. 14. Special Handling Instructions and Additional Information !• . jir- iLl N i 'r ,'s k. l < t ii. ii: K;� Fit),# 1111 i iylFfif3FN(:Y CixT rr,i' f t + ' Yi•u�)1 !_ _ � (..1 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 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 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) (if I am a small quantity generator) is true. Generator'slOfferors Printed/Typed Name Signature Month Day Year 16. International Shipments H ❑ Import to U .S. ❑ Export from U .S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S. : W 17 . Transporter Acknowledgment of Receipt of Materials UJ Transporter 1 Printedffyped Name Signature Month Day Year O a Transporter 2 Printedffyped Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ ❑ ❑ Residue Partial Rejection Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) U .S. EPA ID Number J U LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) 40tice : State of California requires 0 1 . T 3. generator to photocopy and mail to )TSC with 30 days : 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 10 O Box 400 Printedffyped Name Signature ia &amento, CA 95812 -0400 EPA Form 8700-22 (Rev. 12- 17) Previous editions are obsolete. GENERATOR' S INITIAL COPY