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Please print or type . Form Approved , OMB No. 2050.0039 UNIFORM HAZARDOUS 1 . G enerator ID Number 2 . Page 1 0( 3. Emergency Response Phone 4 Manifest Tracking Number JJK WASTE MANIFEST t. , ` °t ' 5 Generators Name and Malting AddressIv sf <- Generator's Site Address (if different than mailing address) let% 1 Xd " $ 1 ,. r" A. s r a : Jell Generators Phone: lf Je ,+ s` 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U .S. EPA ID Number 8, Designated Facility Name and Site Address U.S. EPA ID Number . RI" . 3 Facility's Phone: le ga 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quantity WtNot, . :, 4 0 l If Z 2. U e...._.. _ lee .. _,__ ,,.,...... 3. 4. 14. Special Handling Instructions and Additional Information , ; rel Iv ' r 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by 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'sl0fferor's PrintedlTyped Name Signature Ile , Month Day Year � r � . Ey 16. International Shipments Import v � ❑ Import to U.S. ❑ Export from U .S. Port oven Z Transporter signature (for exports only): Date leaving U .S. : W 17, Transporter Acknowledgment of Receipt of Materials w F� Transporter 1 PrintedlTyped Name Signature Month Day Year ,o co Transporter 2 Printed/Typed Name Signature Month Day Year 18, Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue El Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year B Z 19 . Hazardous Waste Report Management Method Codes (Le' , codes for hazardous waste treatment, disposal, and recycling systems) ® 1 . 2, 3, 4 . 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete , GENERATOR' S INITIAL COPY