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-•••=11..111PPIIM.".11111..1M11.2- /iv Please print or type. (Form designed for use on elite 12 itchtypewriter. Form Aooroved. OMB No. 2050-0039 4 GENERATOR )- I UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone . . 4. Manifeat Tracking Number ... . • • JJK Generators Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: , I Transporter 1 Company Name U.S. EPA ID Number I 7, Transporter 2 Company Name U.S. EPA ID Number I Facility's 8. Designated Facility Name and Site Address U.S. EPA ID Number ..litirtilt.aill *Nat 1491 6.14}erriei 11; it L. "?•1 _Ai 4' %lit II- Fi. i tot.' Phone: TiZ 9 -- .1.?t't ' 7/I I gai 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM add Packing Group (if any)) No. Type Quantity WLNol. 13. Waste Codes 1. 1-- 2. I i I r - I-- ---r----- - I i I 3. - -- - --i- ._ 4 1 i 1 Special Handling Instructions and Additional Information 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 labeledtplacarded, 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. I certify that the waste minimization statement identified in 40 CFR 262.27(a) if lam a large quantity generator) or (b) (If I am aamall quantity generator) is true. Generatots eror's Printed/Typed !Arne ...-, Month Day Year , ,I Signature ---..<4).1 »' ' •_. 4:: :-."-- I Z___ ' -1( I -.J 1- F- 16. International Shipmeflts Import to U.S Export from U.S. 'Port of entry/91dt Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Sign,re - Month Day Year I 0 1 . _ ,_,------ I Transporter 2 Printed/Typed Name ......00S4gnature Month Day Year I I I I DESIGNATED FACILITY 18. Discrepancy Discrepancy Indication Space Quantity LIType Residue LI Partial Rejection LI 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 Faciiity Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as ncted In Item 18a Printed/Typed Nape , Signature .Month Day Year 4,(A 1€,\I ar Ln- ,c , i ql----- 1 t-t-.Lt. uttil Atht4i-------- I EPA Form 8700-22 (Rev. 3-05) Previous editions areOsotete. DESIGNATED FACILITY TO GENERATOR