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iedse print Or type (Form designed for use on elite 12- itCh eWrifer. rm Aogroved. OMB No. 2050-0039 . , GENERATOR . 1 . . UNIFORM HAZARDOUS WASTE MANIFEST 1 G eneraor D Number ' ' — t I 2. Page 1 of 5 Generators Name and Mailing Address JJK 3 Emergency Response Phone 4. Manifest Tracking Number Generators Site Address (if different than mailing address) Generators Phone: 6 Transporter 1 Company Name U.S. EPA ID Number 7 Transporter 2 Company Name U.S. EPA ID Number I '3 Designated Facility Name and Site Address U.S. EPA ID Number F;y_ iftyS Phone: 9a. 9b U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes Him and Packing Group (if any)) 13. No. Type Quantity Wt/Vol. 1 ''''• .1 ..!•,- ': ,r,....ial h.,..•-•:, .n -_ , ,t,:,-±ons and Additional Information ...— GENERATOR S;OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately deschbed above by the proper shipping name, and are classified, packaged, - - • - • .-:, ,. ,..Tplacarried, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and lam the Primary ` ; ,: ••• • - • • , ' ii i'.e contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. on statement identified in 40 CFR 262.27(a) (if) am a large quantity generator) or (b) (if I am a small quantity generator) is true. Signature Month Day Year ; .N, r - *-------- DESIGNATED FACILITY ---* ITRANSPORTERI4JTII Shlriell15 7 Port of entry/exit: IniwridliUllal Export from U.S. Import IOU S. Transporter signature (for exports only): Date leaving U.S.: 17 Transporter Acknowledgment of Receipt of Materials Month Day Year Transporter 1 Printed/Typed Name Signature I 1 ':1. Month Day Year Transporter 2 Printedayped Name Signature I II 18. Discrepancy Discrepancy Indication Space Li Quantity 11 Type Residue Partial Rejection Full Rejection Manifest Reference Number. U.S. EPA ID Number Alternate Facility (or Generator) Facility's Phone: Month Day Year Signature of Alternate Facility (or Generator) VVaste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systems) 19 Hazardous 2. 3. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Signature Month Day Printed/Typed Name Year I_ I I I ...., Forrn 8700-22 (Rev. 3-05) Previous eDitions di . AL C