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Please print or type. (Form designed for use on elite If 2-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 1 , Generator ID Number 2. Pagelof 3. Emergency Response Phone 4. Nanllast7ncking Number JJK WASTE MANIFEST 5, Generators Name and Mailing Address Generator's Site Address (if different than malling address) Generator's Phone: mhar 6. Transporter 1 Company Name U.S. EPA ID Nu 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Facilitya Phone: ga go. US DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 0. Centel am 11 . Total 12. Unit 13. Waste Codes HM and Packing Group (If any)) No. Type Quantity WI.Nol. rr ' BORA RAiARD )US WASTE. SOUD NIL '/ Solu;a'. O z 2. w 3. 4. 14. Special Handling Instructions and Addadral Information ' -1300-429300 WOES TERMINAL r,ERc'S NAERGp 981 171 * PREFILE a 981 APPFOPRIJi 71cRSONAt . PP, OTFCTIYE F0011311 NT 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 tlassifieQpackaged, marked and labeled/placarded, and are in all respects in proper condition for bansppn according m applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I cedily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I canal; that the waste minimization statement identified in 40 CFR 26227(s) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is [me. GeneratarslOfferors PrintedlTyped Name Signature Month Day Year IF F16. Interna8onal Shipments ❑ Import to U.B. El Export from U.S. Pod of entry/exit: Transporter signature (for exports only) Date leaving U.S: K 17. Transporter Acknowledgment of Receipt of Materials Transporter i PrintedRyped Name Signature Month Day Year O as Month Da Year Q Transporter 2Pnnledlryped Name Signature Y 10, Discrepancy 18a. Discrepancy lndtcaBon Space Quantity ❑ Type El Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. led. Alternate Facility (or Generator) U.S. EPA ID Number J U W Facility's Phone: wYear 18c. Signature ofAhemats Facility (or Generator) Month Day 2 O 19. Hazardous Waste Report Management Method Codes (ie.. codes /or hazardous waste treatment, disposal, and recycling systems) 1 , 2. 3. J. 20. Designated Facility Owner or Operator: Certification of reralpt o nannocus materials covered by the manifest except as noted in Item 183 lPrintedfryped Name Signature I Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR -