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11 Total <br />QuantIty 13. Waste Codes <br />Po of entry/ <br />Date leaving <br />[1]. Partial Refection <br />U.S. EPA ID Number <br />CIPutt Rejection <br />Mc th <br />• <br />• • Pub'"Thed byj j. <br />Keller & Assocmtes. Int. • Nponah. WI • ..1.3Keitor cern • (800) <br /> 327•580/3 • Printed m An USA <br />• • <br />177-BLS-C 5 55359 <br />1 2174,1,/ <br />Forrn Appro ed. OMB No 2050-0039 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Cumber 1 et() <br />0G6(0 019949331 JJK Generator's site Address (it dflerent than mailing addik..$) 9 5 (7)0 s 5 q 9 124 SA-0 , CA c1 <br />7 TranspoSer 2 Company Name <br />8 Desigriated Facitily N Jame and Si eAddre,ss <br />F01,00,red 41--tlyNc4 <br />-1()Ic\cA S • A-us+ (V1 az4, 111151.-+A-4-e--cc\f 533Go <br />Facilitys Phone. — — <br />NEt 9b. U.S. DOT Description (includmy Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) <br />10. Containers <br />No Type <br />U.S. EPA ID Number <br />14. Special Hand/ing Instructions and Additional Inforrnalmn <br />*, d•oci — 9 3. —oc,o(4, <br />15 <br />GENERATOR'S/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name, and am classified, padxaged, marked and labeled/placarded, and are in <br />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 <br />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 lam a large quantity generator) Orb) <br /> m a small quantity ye erator) is true Generatoes/Offeror's Printed/Typed Name <br />Signature <br />Export from U.S. <br />17 Transporter Acknowledgment of Receipt of Matenals <br />Transport rintediTy <br />Month Day Y <br />L 'Ee:Tret <br />16. International Shipments iiii Impel toU S. <br />Transporter signature (for exports only): <br />Trans er2 nnte ped Name <br />Signature <br />Month Day Year <br />18 Discrepancy <br />18a. Discrepancy Indication Space <br />86 Alternate Facility (or Generator) <br />Quantify El] Residue <br />Manifest Reference Number. <br />Month Day Year <br />Hazardous Waste Report Management Method Codes (i.e.,codes for hazardous waste treatment, disposal and recycling systems) <br />20. Designated Facility Owner or Operator C,erlificalion of receipt of hazardous materials covered by the manifest except as hoed in Item 18a <br />Signature Pnnted/Typed Name <br />18c. Signature of Altemate Facifily (or Generator) <br />Facility's Phone: <br />DESIGNATED FACILITY TO EPA's e-MA 1FEST SYSTEM EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.