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Please print or type (Form designed for use on elite (1 ) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Nuber <br />WASTE JJ K <br />0066611241 <br />MANIFEST <br />I <br />8-WJ-424—Q" <br />5. Generator's Name and Mailing Address Generator's Site Address (it different than mailing address), <br />Generator's Phone:..- <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />AA <br />�'. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />ON) Bruit AVO. <br />i1f1,; ark, fr4� , 3 CAMM8741F <br />551(1-Tts-OA0 <br />Facility's Phone: <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any)) <br />Quantity <br />Wt./Vol. <br />z <br />2. <br />W <br />r'7 <br />3. <br />4. <br />14. Special Handling Instructorsand Additional Information <br />/. <br />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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgmenl of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(e) (it I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator'slOffero(fyped 's PdntedName Signature Month' Day Year <br />! <br />r <br />J <br />r <br />16. International Shipments <br />❑ Import to U.S. ❑ Export horn U.S. Port of enlrylex6: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TramporterAcknowledgment of Receipt of Materials <br />Transporter 1 Printedrrype,dJ Name Signature Month Day Year <br />2 <br />Transporter Printed4yped Name - Signature Month Day Year <br />r <br />K <br />r- <br />Discrepancy <br />t18. <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />LL <br />Facility's Phone: <br />w <br />18c. Signature ofAhemate Facility (or Generator) <br />Month Day Year <br />Q <br />2 <br />S2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. <br />4. <br />20. Designated Facility Omer or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month Day Year <br />EPA <br />Form 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />