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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number WASTE MANIFEST I 1 1 JJ K 5.Generator's Name and Mailing Address ,.i➢dl'#'0 Arm It+#Ji:l6 Pi.A2.kN Generator's Site Address(if different than mailing address) AJ4914 itMUTON KO 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 NumberA� C-4 L fZ? Facility's Phone: ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. O Z 2. W 0 3. 4. 14.Special Handling Instructions and Additional Information Ils.R. Gt'�RrfP�iAc�Tfll1: F�ttuMJt3!'!taF`1NRC.ff�AEkif,AL HAM"19 $b"0"Be"i'1EAteo AM 1.15r'L APPR CK,011U PM 15. GENERATOR'S/OFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 1 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 16.International Shipments ❑Import to U.S. Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a QTransporter 2 Printed/Typed Name Signature Month Day Year W H 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Full Re ❑Residue Partial Rejection jection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year ZZ C) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2. 3, 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY