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M ........ .,d t e. e..,e lF n deeiened for use en ellre fie-61—Al., 1 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY 7 Generator ID Number U AN '1 2. Page 1 of 3. Emergen Response Phone 4. Manifest 'Tracking jNumber � /� 518043 JJK WASTE MNIFORM EST r° N L D 0 0 3 [ a 7 t 2 LS00-53b-8053 V®I 5 Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: 6. Transporter 1 CompanAame U.S. EPA ID Number fiMT'+Is.R tfS:-! iFdr'. C A 'l.i ti 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number A F, Facditys Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11, Total 12, Unit 13. Waste Codes No, Type HM and Packing Group (if any)) Quantity Wt.Nol. 13 1,; Val, 1a11cdT t, PQ 11 tRrl fit ;, to+ d,.��— ;r r. w z 2A11-gr'R dkra 7TE, :. •`+;:': T; 3. 4, 14. Special Handling Instructions and Additional IMormadon Jj 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am 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 international and national governmental regulations. If export shipment and farn the Primary Exporter, I ceNry 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 hue. GenemtorslOfferoraPrntedlTyped Name Signature Month Day Year 16. International Shipments ❑Import to U.S. El Export from U.S. Port of entrylexiC Transporter signature(for exports only): Date leaving U.S.: w17. Transporter Acknowledgment of Receipt of Materials ry, Transporter l Pr rtedrryped Name �. r-- • , Signature !vI Month Day Year QTransporter 2 Printedryyped Name Signature Month Day Year h 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V Facility's Phone: 18c. Signature of Ntemate Facility(or Generator) Month Day Year a z H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. a. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prntedlryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY