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Form Approved. OMB No. 2050-0039 rICci,SC A UNIFORM-Ii riDOUS WASTE MANIFEST 1/11111, VI typc. k iv l /ii uconelcu IV, YIJG VII Vt.,. ‘ i a. row", by 'Iv, 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number JJK Generator's Name and Maiirg Address Generator's Site Address (if different than mailing address) Generator's 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 Facility's Phone: I 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes ga. HjiA and Packing Group (if any)i No. Type Quantity Wt.Nol. re 0 g w z CD I : 1 14. Special Handling Instructions and Additional Information 15. 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 labeiediplacarded, and are in all respects in proper condition for transport according to applicable internatiorial 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 I am a large quantity generator) or jbi lift am a small quantity generator) is true. Year Generator'siOfferor's Printed/Typed Name Signature Month Day I I I I Y -1 16. International Shipments Port of entry/exit: - t Import to U.S. Export from U.S. Transporter signature (for exports only) Date leaving U.S.: re 17. Transporter Acknowledgment of Receipt of Materials Year 0 az ce Signature Month Day Transporter 1 Printed/Typed Name Year z < cK cil Transporter 2 Pr sled/Typed Name Signature Month Day I I I I I- 18. Discrepancy i 1Ba. Discrepancy Indication Space fl Quantity Type Residue Partial Rejection FuR Rejection Manifest Reference Number: r r, L5 a La- Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Day Year fla t- a Signature of Alternate Facility (cr Generator) Month I I 0 - z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU C3 cr) 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 18a Day Year Printed/Typed Name Signature I Month I I i I rsmnanki Arm-% c Art] ITV Tr) C1Fhl F Pt ATOR EPA Form 8700-22 (Rev. 3-05) PreviouS editions are oosoiete.