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J <br /> Please"print or type.(Form designed for use on elite(12-pitch)typewriter.) "��W 1``'�7'2'�iG Rea <br /> UNIFORM HAZARDOUS 1•Generaror ID Number Form Approved.OMB 1.,. <br /> � y 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tcking umber <br /> WASTE MANIFEST #-ft f3 t'} $t3 ", �. (SOO)4ffT331 11`j�inJ <br /> 5. to's Na e�,aan�ddMM i °°gqd�desfs �,,�9234 <br /> t1r:�3tzti Y �Cfi1� aattille( Generator's Site Address(if different than mailing address) <br /> a a nu <br /> .i�..,r.►.r..e paae a ue est _ <br /> Generator's Phone: M-1 91 9924'ti#44 j <br /> 6.Transporter 1 Company Name <br /> Put <br /> mir <br /> #lifi Harbli1U"s E7t'YFtrUE1v1 ental Gill JIyC U.S.EPA ID Number <br /> inc <br /> 7.Transporter 2 Company Name M A DO :3 9 3 2 2 2 $0 co, <br /> U.S.EPA ID Number <br /> Pr <br /> 8.Designated Facility Name and Site Address <br /> Clea�/lk�'�o►t�'!cws San ROM LLiC U.S.EPA ID Number <br /> 1021 Barrr�r*�laa Read • n c. r` K r rt <br /> Facility's Phone: !4091441-0- <br /> i <br /> ga• 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 0 1. f4A3082-HAZ�f,WASTE,U1111111).N.O..S..fBENZ✓N'C_, <br /> W <br /> 343 <br /> IBJ <br /> X GASOU140-S.PG Of <br /> 0019 352 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1 <br /> 1.rCti�iplg3 # X S` c?iiil <br /> 15. GENERATOR'SlOFFEROR'SCERTIFICATION: Thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)-or(b)(if I am a small quantity <br /> Offeror s Printed/Typed Name q ty generator)is true, <br /> enerator . <br /> igna re <br /> f �_'"'-" t',•.. �...:i � Monthay ear <br /> --r 16.International Shipments ' s <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Trans'orter si nature for ex orts onl <br /> W 17.TransporterAcknowledgment of Receipt of Materials Date leavin U.S.: <br /> Transportef 1 PrintedrTyped Name <br /> 00 # /' Signature <br /> W } ��-�/ Al I `i on aY ear <br /> Q Transporter 2 Printed(Typed Name �� I I I <br /> ignature Monthy <br /> a Year <br /> 18.Discrepancy <br /> 18a•Discrepancy Indication Space <br /> ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> Number <br /> U <br /> Q <br /> LL Facili s Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> F— <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Was Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> ##� � 2 ;receipt <br /> 4i 3' 4. <br /> 20.Designated Facility Owner or Operator.Certification of o;hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name <br /> Signature Month DayYear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> 0488 AfIllm nag the all popriate Permits iinr al 1,141 a€,;rpt'he wuae M?;yrtermll as it afl GENERATOR'S INITIAL COPY <br />