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r <br />Please print or e. (Farre deal nod for use an elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Gerrerator ID Number 2. Page 1 of 3. Emergency Response Phone 4. MaNfesl Tracking Number <br />WASTE MANIFEST CAL1.OW-WAA55 _ i I FY 371.5: 4? 017145319 J J K <br />5. Genereta s Name and Mailing Address GenelBtor's She Add7s(If�lfierent than mallng, address) <br />r31 >Fi"1E?t f : IC l 4 <br />irk tF•ifMi`s`ii�ai :':`,i = SI' <br />�TJCVTOK CA 'Y&, t-4 <br />Generatoes Phon6W 4370--1:' <br />6. Transporter t Company Name U.S. EPA ID Number <br />}I'.l'fniOGAM44 <br />7. Transporter 2 Company Name I I_S_ FPA In Nnmhw <br />C. Uesagnarea really name ana Shia Acoress,4!0UA 163 TECtit41a4R' U.S. EPA ID Number <br />RUXit if), CA 34^ 1 <br />FadItys Phone:ii�l0 .13» <br />8e, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Contah(a f1. Total 12. Unit 13. Waste Codes <br />HM and Paddng Group Cd any)) No. Type Quantity WLIVOI. <br />1. r r r"471 -MM -3- uur k <br />SOLID, F.1C14, 9, Porti CCH0RMi1. . LEAD) <br />;--q <br />j. <br />zr ` <br />46 <br />14. Special Handling Instructions and Additional Information 11 4£ c r a <br />W-I)MIFILE4 iFPGAT1 q&]) rtUi°ttM fti` tai <br />E:W, Gt�<s1i�°At:T f#,4 l ' MAPON04VITAL - <br />1' MIDL".y 19110.8.!! VIE TVRA.+" A -No I MIEN AVP RO. l r. D PPS' <br />1w f <br />16. GFNERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and. are dassiflad,. packaged, .." <br />marked and labek drplocarded, and are in all respects in proper condition for transport according to appkabie Intematlonal and national govemmental regulations. M export shipment and I am the Primaq( ' <br />Exporter, I certify that the contents of this oonslgnment oordorm to the terms of the attached EPA Acknowledgment of Consent <br />I certify that tite waste mlhimizatiort statement fdentilled In 40 CFR 262.27(a) (If I.am a large quantity general* or (b) jin am a small quenttiy generator) Is true.. <br />GenereWs101fBrorS PdnWTyped Name S1grVdjw•r-'' flow YM.r <br />8 .fntamatlonal Shipments <br />❑ Import to U.S. ❑ Export from U.S hbrlahiofo <br />yltad) <br />Transporter signature (for exports only): ke+kg U.3.: <br />17. TransporterAcImMedgmerd of Receipt of Materials A, <br />154-arisporter 1 P ntedlTyppd flame i Signature <br />�..,..-n [YA..i..JR. �..J �f....... ft .. ..unnffi rYNV <br />18. Discrepancy I --f <br />18a. Discrepancy Indication Space❑ I__t.FuM. <br />❑ Quantity El Type ❑Residue Partial Rejection <br />Manifest Raferance Number <br />18b. Alternate Fadtily (or Generator) U.S. EPA ID Number <br />Fads Phone: <br />W 18c. Signature of Alternate Facility (or Generator) Month <br />N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systema) <br />C 1. 2. 3. 4 <br />20. Dedgnated Faclgty Owner or Operator. Certification of receipt of hazardous materials covered by the mantlest except as rioted In Item 18a <br />dntedrfypedName Signature Day <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INMAL COPY <br />