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lelase 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 — JJ K 1, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) i Generator's Phone: B. Transporter 1 Company Name U.S. EPA ID Number I C 7. Transporter 2 Company Name I U.S. EPA ID Number i 8. Designated Facility Name and Site Address U.S. EPA ID Number i Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type Y + Jt 2: 9 4 ( ,. ..), A� t .... �� i� " � i� " !'"fid !� �rY ✓°'��a°E ^'�' 14. Special Handling Instructions and Additional Information r; r� t �i K '^ a .;¢ r,� �: 'I r�fr• �fi ?`� `qtr _ ;f t:, , t f•+t-' §)` .: <;'� � •�.��.--�~--_ `• PO?f ,^TT4t" r ! Z±T (�tSdt ��.!3HR +=t0f I7,mr a s fd r3t3) 13 a--"xe`�F--t;i�#ti ( ( 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 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. Gehprator's/Offerors Printed/Typed Name Signature Month Day Year 16. International Shipments '= ❑ Import to U.S. El Export from U.S. Port of entry/exit: _. I Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials _iTransporter 1'Piinted/Typed'Name Signature Month Day Year Transporter 2 Printed/Typed Name .Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ QuantityType El ❑Residue ❑Partial Rejection ❑Full Rejection i Manifest Reference Number: s 18b. Alternate Facility (or Generator) U.S. EPA ID Number j( 4 Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Month Day Year C� 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 2. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTypedName ;' Signature Moni1 Day Year 'A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DrES116KII A-TEX4 �, a t t J',r