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-ined for use on elft (12-pitcl., ;writer.) Form Approved.OMB No.2050-0039 .JUS 1.Generator ID Nu er 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number .1rEST JJ K s Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: ' 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Sh ping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantify Wt.Nol. 0 J Z 2. LU C7 � i 3. �. 4. i 14.Special Handling Instructions and Additional Informa'on 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I lereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,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 certify that the contents of this consignm nt conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Went fled in 40 CFR 262.27(x)('rf I am a large quantity generator)or(b)(if I am a small quantity generator)is true. 'enerator's/Offeror's Printedrryped Name Signature Month Day Year 16.International Shipments H ❑Import to U.S. ❑Export from U.S. —iPort of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedrryped Name`-7 Signature Month Day Year U) ZQ Transporter 2 Printedrryped Name Signature Month Day Year 4 H 18.Discrepancy 18a.Discrepancy Indication Space El Quantity E Type L1 Residue El Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J C.) Facility's Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year Q 2 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. T. 4. 1 - 20.Designated Facility Owner or Operator:Certification of eceipt of hazardous materials covered by the manifest except as noted in Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are ob olete. GENERATOR'S INITIAL COPY