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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS 1.GeneratorlD Number 2.Pagelof 3.Emergency Response Phone TMnanileest Trackin Number <br /> WASTE MANIFEST 'CA!^D4Y,t�g"Fr,•? 1 11i,371- •!7 IJ J.�� 049 , JJK <br /> ' 5.Generators Name and Mailing Address Generators NteAddmss undinament Nan mailing address) <br /> f k W't5T h X311.:1i D, <br /> ST(X:'KTGMr,CA jA'sW <br /> Generators Phonei"1±z�44N.itk1? <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ' F`P,P.h3•� LhtrllCCkM;,�A11',41,.�:.Tx'4gCE::�1>'8G. t'..ADI]i4L�1'_i.°?,;. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 9t1U.S.EPA ID Number <br /> xaf<W r�.,utIF�4�ReCojrEw <br /> 910)E''S T Psci)"L'.'D. C+n171Yk4¢;:J4':iE. <br /> LGI.'io AN1ftf7,S,CA SiC.+tj'Ts;y <br /> Facilitys Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Dentalnere 11.Total 12.Unit <br /> HM and Packing Group(If any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 1. t,dim,vw.e r f 1., INTAt li ';Oci} rt1FOATitc, NCYZ' d 1,F'CiNIiJ41 i.7fi,° P ;' '2 F3011i DOW <br /> ap i'^^erl'rN001£'.FILM,-)REGUVtu <br /> r - <br /> wIF <br /> z 2. <br /> fw7 <br /> 3. SEPI 10 2014 <br /> 4. <br /> DEPARTMENT <br /> 14.Special Handling Instructions and Addifional Information <br /> HrF31}f+P:flFftA�'A <br /> 'K.e? QOPITRAG'rf'iR.: RAF.R:rir gM1lVIF3!l!':dh4k:'.h4Tt p.. <br /> t4.a1g011-":tr`.r .ytirjtgi..4T kl£?TY+?4tRlfit) �dro tl?+f,.''hr�'H-FU'4`E'll F'P�k: ' <br /> i <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are clashed,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulators.If export shipment and I am the Primary <br /> Exporter,I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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)(ifI am a small quantity generator)Is true. <br /> Generatoes/Ofiemrs Printedfryped Name Signature Month Day Year <br /> ...r 16.International Shipments s•. <br /> Z ❑Import to U.S. ❑Export from U.S. Pon of entry/exit: <br /> Transporter signature(for exports only): ` ""+"'"'""'^"` '�`^'"'"'"' Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Si nature Month Dayr <br /> 9 Yea <br /> M Trensponer2Pdnlednyped Name Signature 9 Month Day Year <br /> H <br /> }, 18.Discrepancy , <br /> 18s.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manliest Referenco Number. <br /> IdD.Almrnate Facility(or Genemtor) <br /> � U.S.EPA ID Number <br /> U <br /> ra+. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> p.. Month Day Year <br /> z <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded In Item IBa <br /> Printed/ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />