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- - <br />7144 rtt.- c, Do 2 <br />Please print or type. (Form designed for use on elite 12 itchtypewriter.) <br />A <br />re <br />0 <br />g ul z tu <br />0 <br />V <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />JJK <br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />157 7 ? hicomatvi RCI <br />Lail/top. 12.• 4'; 3 111) <br />Generator's Phone: 35-'5 6429 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />I <br />Transporter 2 Company Name U.S. EPA ID Number <br />I. <br />Designated Facilky Name and Site Address U.S. EPA ID Number <br />353$ I Oki Sithytire R f.siki <br /> <br />I KAINIPMon City. C.• <br />Facility's Phone: 59- .3eF. 711 I <br />ga. 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit <br />NM and Packing Group (if any)) No. Type Quantity Wt.Nof. 13. Waste Codes <br /> I <br />I <br />, <br />i <br /> <br />1 <br />' <br /> <br />_ <br /> <br />— , — <br />1 <br />14, Special Handling Instructions and Additional Information <br />......,-.. , <br />15. GENERATOR'S1OFFEROR'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, <br />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 <br />Exporter, I certify that the contents cf this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (to) (if I am a small quantity generator) is true. <br />Month Day Year Generator'srOfferors PrintectrTypedName Sigaature <br />-- a, I --- ( ..—•p,.../ 4-0....,.. z...-) I' ;='-'"------7 -. , I -.1 <br />F- <br />- <br />1671Mernational Shi ts LI ..) Import to U.S. Export from U.S. - Port of entry/exit <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />. , / .." <br /> <br />- , <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I '(-- DESIGNATED FACILITY --+ 18. Discrepancy <br />Discrepancy Indication Space El Quantity Type Residue Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />18. Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal and recycling systems) <br />1. 2. 3. 4. <br />20. Designated Facility Owner or Operator: Cerrication of rec:eipt of hazarcknis materials covered by the Manifest except as ncted in Rem 18a <br />Printed/Typed Name Signatime a ..i..4ti,„_____ Month Day Year Y)r.nr-, Co(' \evi....f ,_ , 1 . l,' I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR