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IT777 Please print or type.(Form designed for us. ; eflte{12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.GerfieratoriD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST r1 . 017617002 JJ K 5.Generator's Name and Mailing Address •t A Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number �= e I&V k r-0 JkJ tee 4 45e r44Q J K CAR 000 171011 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number JoLo F 3fwAIJA C.ant� a ke r 5 C AL Q O o�3ot S9 Facility's Phone: 9a 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)) No. Type Quantity Wt.Nol. 13.Waste Codes 1 Noiv RCRA 0 ©o1 Tr V6500 o'1613; z 2. Lu 3. i i 4. --+ -- - I 14.Special Handling Instructions and Additional Information E.R, G V? 4AA�11rr5 40 � �'�wea �� I we4r pt�C 15. GENERATOR'SIOFFEROR'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 intemational and national governmental regulations.If export shipment and I am the Primary ;1 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)op(tr ('d I am a small quantity generator)is true. Generat&W.Offeror's Printedrryp d Name Signature i Month Day Year -J 16.International Sh ments i— ❑Import to U.S. ❑Export from U.S. ( Port of entry/exit: z Transporter signature(for exports only): '—�Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials Transpor 1 Pnntedrryped Name Signature Month Day Year 1,0/0 113 co -7-Aea Arm Alo 4A Z Transporter 2 Pnated/Typed Name Signature Month Day Year Q H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operafor.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pri 7drred Name Sigoltur f Month y; ear �,� � EPA Form 8700-22(Rev.3-05) Previous 'ons are obsolete TRANSPORTER'S COPY u