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- --wwwwww•-- -rylit ""'" PS ZS '# Please print or type. (Forridesigned for use on elite (12-pitch) typewriter. For Approved.0MB No.2050-0039 • re 0 ...(1-- 2 1.1 UN WORM HAZARDOUS WASTE MANIFEST I. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number 018640050 JJK Generator's Name and Mang Address Generator's Site Address (if different than mailing address) Generators Phone: I Transporter 1 Company Name US. EPA ID Number I Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address US. EPA ID Number L.iin:. d.: :::::.14 liZe Mtaria9erriv..i . 4251 Old SkrIk* ROM.' V.iftiman C*9 , C ti 932 iiii Facility's Phone: r;',// I 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)) No. Type Quantity Wt.Nol. 13. Waste Codes . I I ...._ 4 GENE I i i 1 I I 14. Special Handling Instructions and Additional Information 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 classified, packaged, marked and labeledtplacanied, and are in all respects in proper condition for traniport according to appficable international and national governmental regulatiolb tf 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. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or4144iflark4arnall quantity generator) is true Generatoes/Offeror's Printed/Typed Name Sighature ----- _.. Month Day Year .1 i- g 16. International Shi4lents Import to U.S. Export from U.S. ' ort of entrylexit: Transporter signature (for exports only) Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year } '-‘): V..' r: 1:-,' .- I I I I 4 Transporter 2 Printed/Typed Name Signature Month Day Year I I I I . I 4--- DESIGNATED FACILITY ---0- 18. Discrepancy Discrepancy Indication Space E Quantity Type Residue Partial Re;ectIon Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Altemate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a Printed/Typed Name Signature Month Day Year L I ' I I - EPA Form 8700-22 (Rev. 3-05) Previous editions aiv obsolete. DESIGNATED FACILITY TO GENERATOR