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•02/09/2011 12:24 209-467-0654 CONTI MATERIALS PAGE 03/03 <br />Please prinlore. (Form designed for use on elite (12 -pitch) typawrlter.) <br />Form ApDmved. OMEI No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are oosorere., VIF—AN V—" �' <br />UNIFORM HAZARDOUS <br />1. Generator 10 Number <br />2. Page 1 of <br />3, Emorgerrvj Response Phone <br />41 Manifest Tracking Number <br />WASTE MANIFESTI.,007269130 <br />JJ K <br />S. Generator's Name and Mating Address G9nOretof s SRA Addrm Of different Utan mating address) <br />ri <br />GBnaahrsVYnbt19': '~� t.i• ril;,�Oiovi ::31�n.M?i ii (.P <br />6, Transporter i Company Name U.S. EPA ID Number <br />u r: <br />7, Transpormr 2'Company Name U.S. EPA t0 Number <br />a. Dmlgrtated Facility Name and SiloAddreea U.S, EPA 10 Number <br />"7'''�;1�•r i;. i i•;'I'fi t113� <br />V41W 11,011 <br />'; <br />9a. <br />9b. ILIA DOT DOscrtpBon (Indu Proper 8h0pinq Name, Hazard Class, ID Number, <br />14, contalnare <br />11. Total <br />12. Unit <br />HM <br />and Padit amp Of any)) <br />Quantity <br />Vdt,/Val, <br />13. Waste Codes <br />No. <br />Type <br />Q <br />Ir'%�s >' 1)i .,:ti a) ai,.rt, s•:t'!; .:a�;,'w.r: ;111':jt(e»;,i1� E <br />! <br />i <br />ED <br />� r <br />('� v r i j r %✓ '''"' i. !� t r` <br />�% <br />J•' <br />. <br />V <br />i {i !' , <br />13, <br />4. <br />,i <br />14. Special Handling instructions and Additional Information <br />Utif;,rte`: *7i;f- T. i4: t,3 :i f i'J, i~1�rik•i•`S.sir•%i.� +'•.f.�7��s}`M:) CHAVI P' .'ii4.aY0N xAI't;1-plFri'e.i �� i��i1,1 41 <br />15. GEN ERATORISIOFFEROR'S CERTIFICATION: I hereby declare that the contarrta of thla cansignmerd are fully end accurately deacribad.abova byiha proper sNppfng name, and are dar7elOed, pnekaged, <br />morkod and Iabeledlplecarded, and are In an respeota In proper mndhkn for transport according ro applicable international and r atimk� govommorlal regulatlOns, If export shipment and I am tho Primary <br />Evoder, I corny that the contents of this eonoignmant conform to the terms of the attached EPAAcla C dgmant of Consent. <br />I og!dly that the waste mlrilmization afoternent IdentlRed In 40 CFR 262,27(x) (If I am a forgo quhnllty generator) or (b) (Ir I am a small quontlty.goneraior) is true. <br />GenaratorslOffemrs Printedffypod Name Signature „- ;a"' '— — Momh Day Year <br />1 <br />— <br />% Intgrnetional Shipments <br />❑ Import to U.S. ❑ Export from U.S. � <br />a <br />Transporter signahrra (for emorts only): Dora leasing U.S.: <br />Ex <br />17. Transporter Aclmewledgment of Receipt of Matedals l <br />a <br />Transporter 1 Printedlfyped Name/, Slgnetum , •�} •' l' Manih Day Year <br />4 <br />NJ <br />Transporter 2 Pndted7yped Name S gnefire, r Month Day Year <br />r <br />19. Discrepancy <br />18a. DlscrepAncy Indication Space ❑ Realdue ❑ ParRal Rejeodon ❑ Full Rejection <br />Quantity Type <br />Manlfw Reference Number. <br />76b.Altem9to Facility (or Generator) U,S, EPA ID Number <br />J <br />U <br />L� <br />Facilltv'sPhone: Month Day Year <br />C <br />W <br />1 Br. Slgnaturn of Aar mato Fnclk (cr GonArAtnr) <br />a <br />' <br />z <br />N10, <br />Hazardous Weate Report Management Method Codas (i.e., cods for hazardous waste treatment, disposal, <br />And racong systems) <br />UJ <br />t 2. <br />3. 4• <br />ated FacIIRy Owner or Operator. Cortitc9on of reCdpt of hazardous materials covered by the manlfesr inapt as r>ded In Item tae <br />anth Day Yea <br />FIZ/Ty�pL-dName Slgnetum <br />n ru.n-n Ar rrnDV <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are oosorere., VIF—AN V—" �' <br />