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-rcotic— _Ls." Loo044-... Please print or type. (Form designed for use on elite (12-pitch) typewriter. Form A roved. OMB No. 2050-0039 4 GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJK Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Generators Phone: I Transporter 1 Company Name U.S. EPA ID Number I Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address U.S. EPA ID Number ‘ cria..,thr o'..tioir Maiti lij&!....i it Lit-- 35451 Cild Sikylirie Fi,LuTi•.! Foreman GIN , (- 4 9 5 Facility's Phone: I ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit NM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes 1. 2. 3. , 14. Special Handling Instructions and Additional Information , i.. - / , irlj . ......,,.._., .., _ _ 15. GENERATOR'S/OFFERORS 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 labeledfplacarded, 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 lam a large quantity generator) or (b) (if I am a small quantity generator) is true, Generators/Offerors PrintedfTyped Name Signature Month Day Year I I I I .../ r- - 16. International Shipments Import to U.S. Export from U.S. Port of entry/exit: 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 I.- -• iVA . t, I I I I Transporter 2 Printed/Typed Name Signature Month Day Year I I I I 4-- DESIGNATED FACILITY -0- 1 18. Discrepancy Discrepancy Indication Space LII 0 Quantity Type Residue Partial Rejection [1 Full Rejection Manifest Reference Number. Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: 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) I. , , ... 2. 3. 4. 20. Designated Faclity Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ruled in !tern 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR