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Please Drint or tvw. (Form designed for use on eUte (12 -Ditch) tvDewdter.) <br />Fnrrn Annmval nMR Un 4r1gaMIl4 <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CALI('13�iS&',v <br />2 Page 1 of <br />3. Emergency Response Phoma <br />4, Maanliest Tracking Number <br />1,017145320. <br />WASTE MANIFEST <br />11x37110& IV <br />' JERK <br />5, Generator's Name and Mailing Address Generator's Site Address (If dMerent than nailing address) <br />&DIR Tt".CH V'JIS;OLft. R{?£MC <br />1" MIX)S?Tt IAL rpt. -' C'73 ^'!r,'3 A = <br />S1W.:KTrA1, CA X19 <br />Generators - •r;+ ..._ .. .. _ <br />0. Transporter 1 Company Name U.S. EPA ID Number <br />- RTWS EPP-I(r't1, ... �.. VITAL S{.11w VIS R1M. :'q 7' q+l•I i' <br />7. Transporter 2 Company Name US EPA IDNumber <br />0. Designated Facility Name and Site Address U.S. EPA ID Number <br />II @:r!tit1N"ct004"ri1L SwT?',xGEy INC <br />11315 '2Xr RVeR R0. <br />WEST SphCRAME11414.1 CA 9t W4 <br />Fafts Phone1 <br />grt. <br />.. ,lab. U.S. DOT Description Qndudi g Proper Shipping Name, Hazard Class, ID Number, <br />10.,Contelners <br />11. Total <br />f2 Uldt <br />13 y Cady •' "' ' <br />No. <br />Type <br />HIM <br />and Packing Group (If any)) <br />Quantity <br />WtAbl. <br />1. 01004 PCPA 1 ,7APV-3tla WA.-vT, SU0 X011 , P.1 <br />001 <br />0141 <br />^` <br />P : <br />' <br />l <br />t4:Spe ialHandlingInstuctionsandAdditionalInformatiori 1 � <br />r �• j7 f <br />`�t��� ��Tt fie r'. � � .. <br />ea- Cr3lk1TTtACII- ; RAMOS E1��TFtr�it+aEM1�1. ,� <br />HAR4t)L1!I*9 UOM VIE TR.A1TdF11 AM 1 -Me APPR(Y-o`!!V <br />jy'.f._•� O <br />15. GENERATTNt'SAOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignrment are fully and accurately described above by the propershipping name, and are classified, pa i; ° r <br />marked and labelod(piacarded, and are in all respects In proper condition for transport according to applicable Intemalonal and national governmental regulations. If export shipment and l am the PrirpaT::'`i r <br />Exporter, I certify that the contents of this consNmment conform to the terms of the attached EPA Acknowledgment of Consent ' <br />I car* Hat the waste mtnimizalon statement Identified In 40 CFR 282.27(a): Of I am a large quantity generator) or (b) (d I am a small quantity generator) Is true. <br />Genarabr'slOtenoft PdhtedfTyped Name Signature Month Dsy Vbw <br />—j' <br />F <br />. International Shipments <br />❑ Import to 11:S. ❑ Export fiom U.S. Pbrt of enlryfemdt <br />Z <br />. Transporter signature (for exports only): Date leaving U.S.: <br />17. TrahsporterAdrnowledgment of Receipt of Materials <br />me DaY Y* <br />CL <br />Transporter l PrIntecryp4marriatSIA ; <br />ce <br />Transporter 2 Pdnted/Typed Name 11646ature Morin .: -DO 'filer , <br />1S. Discrepancy a <br />18a. Discaepan y� Indication Space ❑ Quantity ❑ Type ❑ Residue Ll Partial R*ctlon ❑.W Rein.' _ <br />Manifest Reference Number, <br />18b. Alternate Facility (or Generator) U.S. EPA ID Nwrber ,. <br />v <br />Facity's Phone: <br />C3 <br />18t. Signature ofAltemate Facility (or Generator) <br />Day Year <br />it Hazardous Waste Report Management Method Codes 0., codes for hazardous waste treatment, disposal, and recycling systems) <br />Q. <br />1 • <br />2. <br />3. - <br />4 <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manliest except as noted in Item 18e <br />Pdntedrfyped Name Signature Month Day <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />