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f ' <br />Please rint or tvne (Form designed for use on elite (12 -pitch) hmewrbrj <br />Form Approved. OMB No. 2050-0039 <br />A Forth 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />P <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />3i't fir'S7 <br />4. Manifest Tracking Number <br />017145319 JJ K <br />WASTE MANIFEST <br />Lt f33 ,� . _.r: <br />i <br />IEs <br />5, Generator's Name and Mailing Address `•' • Generator's Site AddTT (If I!Iarent than mailing address) <br />L'1f$IfCTL'tv'hl ; - .. , yrs `•,L.'r; : ti l/. J 7 r J l €. <br />►fes ta1n+,� ,:al = +,t. <br />3TOCNTON. C.A ~a+; <br />Generator's Phon6W 414)-r-'1:7 <br />8. Transporter t Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Deslgnted Facility Name and Site AddressUA U.S. EPA ID Number <br />`•. 7tfft TECt{t t, : ffTk3itLi; C:J!T4' 1I1U7T <br />I t25 HENSL if 5 -' <br />Flt,ls?,r iU, CA 94: 1+ <br />Faclil s Phone <br />ga. <br />9b. U.S. DOT Description (Irdudsrg Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Weale Codes <br />No. <br />Type <br />HM <br />and Packing Group Cd any)) <br />Quenilty <br />WL/Val. <br />1. <br />alta, P.1139, 9, PON iCt•f[1PfW1.(tid, LISAIM <br />g -4 Ll <br />Z2 <br />a 0"V"t x_ a -, <br />LU <br />Ca <br />t. <br />4.Special Handling Instructions and AWttonal Information <br />17IP19P`tl. liyF,Ylg71 9 3}F}FrtO!°tL �Flrsl?1 'c•' .,. <br />fl <br />LtiR. COMTRAiCTCd�t: ft,AU0Px EPM'PONI14EWTr1L <br />ii'iPJ9Lil1ESN-� �r114".AJt.IQ � lF?��'d�.i .A�91J�5'C +�'f�F�,� PPL i r ;; � _,:' ` • � ., �'.� . <br />r <br />r+ r <br />t5. GFNERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are full/ and accurately described above by the proper shipping name, and. are rdesWed, packaged, :. <br />marked and labeledfplacarded, and are In all respects In proper condition for transport according to applicable intematlonal and national governmental regrdatlems. K export shipmentand I am the Primary. <br />Ezporfst, t certify that the contents of this consignment conform to the. terms of the attached EPA Acknowledgment of Consent <br />I certify, 1* the waste mlNmlzadon statement Identified In 40 CFR 202.27(a) (If l.am a large quantity generator) or (b) JIn am a small quantity generator) Is true.. <br />Generalpr'slOReroes Printed/Typed Name Sigrrattr[q XF :.. <br />— <br />18:.Intemallonal Shipments <br />❑ Import to U.S. ❑ Export from U.S Pbrt of'entrylexfC ; <br />rX <br />Transporter signature (for exports only): ate leaving U.S.: <br />17. Transporter Adaawledgment of Receipt of Materials <br />T{SraasportertlP'{/rynted/lyp@d i ... �Do, <br />Transporter 2 PrintedFryped Name Soidure MaMh DSR Y <br />18, Discrepancy <br />18a. DiscrepancyIndication Simco ❑ Quantity ❑Type ❑ResWue ❑PartlalReledlon •�FuN.ReJeplal�_ _ <br />ManlfeatReference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />' <br />LL <br />Fadlitys Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />aw <br />HLLJ <br />19. Hazardous Waste Report Management Method Codes (i.e., oodes for hazardous waste treatment, disposal, and recycling systema) _ <br />1. <br />2. <br />3. <br />20. Designated Facility Omer or Operator. Certification of receipt of hazardous materials covered by the manliest except as noted in Item 18a <br />PrIntaCyped Name Signature Day Year <br />71 <br />A Forth 8700.22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />