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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Fonn Approved.OMB No.2050-0039 <br /> 4 UNIFORM HAZARDOUS <br /> FIG or ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST _ G p C <br /> or .,:, � i is U U r <br /> 5.Generators Name and Mailing Address "" G MI it Umati(if different mailing address) <br /> Yti. iEY )�NT 712f.K Y:1Ne, <br /> 11d?W C}hw Itf-' Y WAY <br /> Generators Phone:. , <br /> 6,Transporter 1 Cor rp y ttta U.S.EPA ID Number <br /> &9#0t'11PdAHt)F:SyCN,i 1II IiM, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> t.rt�RA t+ti�fi4.:Hf!t;tJFtI,K,�VA,I Li.. <br /> t If135 M�YyTE RQ(.k Fu5 ( f+iaUE~rItY�A irK+ <br /> FZAMt:.HfJ CY}I'fi17!)+>k7, <br /> CA 4574 7 <br /> Fadlity's Phone: " t1 r "}Yi1H[r <br /> Or Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group)if any)) No. Type Quantity WI.Nol. 13.Waste Codes <br /> • , MAIL,,, RECEIPT "Ale <br /> r (DOMestic Mail Only;No Ins1rance coverage Provided) 1073 <br /> r <br /> o <br /> 11 OFFICIAL USE <br /> a P Postage $ <br /> a <br /> n Ced9ed Fee <br /> Return R eipt Fee Postmark <br /> ? (Endorsement Required) Here <br /> ] ' 'tooted Delivery Fee <br /> reement Required) <br /> Total Postage 9 Fees $ <br /> 3 <br /> 3 sent o <br /> 3 s`aeec Apr.Na; !, •-••••••'-'•-•"••••_._--•.••.•••..••_•-.-•••--.. g y y�. Y pershl "m name,artl'ard da <br /> g or y,sts No�V . ...-_ tort according to applicable intemallonal nd national governmental regulations.if export sh am the ckaged, <br /> ` :1.. s of this si ent r' n a mtel d s d bove b the <br /> - Q/N.smie-i"N ---'-- •"•••-••-••—•--------• 9 DP gp ipmenl and I am the Primary <br /> attached EPAAcknoWedgment of Consent. <br /> ;,, ,, n a large quantity generator)or(b)(if i am a small quantity generator)is true. <br /> #44110VI FT Signature V <br /> t Month Day Year <br /> ° �... i /. <br /> —+ 16 Interna tonal p encs <br /> iImport 10'U—S.. El Export from U.S. Pon of enirylexi: <br /> Transporter signature(tor exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 cin"typetl Name Signalure Month Day Year <br /> a <br /> 4 Transpo r P nt rr ed m Signatu - nt Day ^Year <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Per tai Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> iBb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. Notice:New federal form. State of <br /> California requires generator to photocopy <br /> +II 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted mail to DTSC within 30 days: <br /> in Item i6e y <br /> Printedrryped Name Signature P.O.Box 400,Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> we•u�w•�ww,w n.m•. wwnv <br />