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,--)4#1,5 75-1 - Please print or type. (Form designed for use on elite (12-pitch)writer. Form Aøgroved. OMB No 2050-0039 ERATOR )... I UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number 9111 C ACt08 14800 2. Page 1 of 3. Emergency Response Phone 4. Magitest Traci? Number .. _ i. 018 .400,5,7 JJK Generators Name and Mailing Address Generators Site Address (if different than mailing address) .. .it CC.4... 161 7 1 HOsitanC.1 F44.1 Generators Phone?1558412c4 I Transporter 1 Company Name U.S. EPA ID Number I 7, Transporter 2 Company Name U.S. EPA ID Number I 8. Designated Facility Name and Site Address U.S. EPA ID Number „ 1626 1 ...Act iity111* 01,44N3 Kellirrnan Clbi, C. • it 3 2A+ Facility's Phone: 51%. MA' 4 ' I 1 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 WiNol. 13. Waste Codes 1 ION fItCftik. MtiVirii_tf M ii1r t r • '7 -it r 1.to I z tu • CD 2. 3. I I 1 I I _ I I i 14. Spedal Handling Instructions and Additional Information ... PS I_ 4 61 07 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 labetedlphacarded. and are in aft respects in proper condition for transport according to applicable-international and national governmental regulations, If export.shipment and 1 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) or (b)(ifi an, a small quantity generator) is true. Genetaqs'Offerors Printed/Typed Name! Signatute, . Month Day Year ''' ""' f- ; ' '' /4 .' ' '• ..-- .._ . " i‘ /..' 2 \ ' I • I _i F- F. 16. International Shipment( / Import to U.S. Export from U.S. .. port of entry/exit: Transporter signature (for exports only) Date leaving U.S.: w tit ri . .. z 17. Transporter Acknowledgment of Receipt of Materials Transrter 1 Printed/Typed Name Signature Month Day Year , ; No d„.“,„.,. i_,,,,,,,,_---....... I __.--..-.: I - ct cc I- Transporter 2 Printed/typed Name Signature Month Day Year I I I I I ' DESIGNATED FACILITY --0- 18. Discrepancy Discrepancy Indication Space LI Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate 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 noted in Item 185 Printedffyped Name Signature ' Month Day, Year t.i.k.kle., )Ar. 0 L(CIL-- 1 W- 44/11/0 kg (-----. I EPA Form 8700-22 (Rev. 3-05) Previous editions ate obsolete. DESIGNATED FACILITY TO GENERATOR