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'Please print or type.(Form designed for use on elite(12-pitch)ty ifar.) • Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 7,111 3.Emergency Response Phone 4.Ma1nnifest Tredung Number 5.GGeneratorsJJ K Generators Name and Mailing Address Generators Site Address Qrunferent than mailing address) q s Generators Phone: 6.Transporter i Company Name U.S.EPA ID Number U S 7 � Sofv 5 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address ,r .tl U.S.EPA ID Number 0S UCD1-aG y N EV q DA Oe T S �l M It e S Of gOF-'q t' ' �✓ � U 4b�j Z 9 d° � T Facility's Phone: 0 G_ l '' 517%, ? V l- —: U3 0 �d ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WWoI. VA 3a-� H AZA(LD6u 5 k)65Tt, 9>1r(19i DoOZ' 1gI �? lay) HAA wl7.dl Z 2' 3. i 4. 14.Special Handling Instuctions and Additional Information 15. GENERATORS/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignmentam fully and accuratelydescribed above by the prepershipping name,and areclassified,packaged, marked and labeladlplawNed,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 certty,that the contents of this consignment conform to the tenns 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)or(b)(if I am a small quantity generator)is true. GeneratorslOferors Printed/ryped Name Signature .. Month Day Year J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Pod ofentry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 Prnted/Typed Name Signature Monty Da Year y a ZZ Transporter2 Printed/Typed Name Signature Month Day Year K F 18.Discrepancy "d T ® 18a.Discrepancy Indication Space ❑ Quantity Type si cit' ❑ YP ❑PaNal Rejection ❑Full Rejection MAY Q` es nce Number. r 18b.Altemate Facility(or Generator) -- U.S.EPA ID Number J_ [yam RO LL Facilitys Phone: I�MIT!"f= W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z y19.Hazardous Waste Report Management Method Codes(i.e.,odes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY