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Pleas(i print or type,(Form designed for use on elite(12-pitcher.) Form Approved.OMB No.2050-0039 <br /> } UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST "�'�'' `'�`�"�b''1 <br /> -At'.-0-4AA-1760 1000796700 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if amerent than mailing address) <br /> - - i•`,1 TYi F:Ci1ER <br /> Lill: C. ht Ji`5i' <br /> Generator's Phone: - - -623D <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAF if "'.-F1715, IINIC T?R0000tCr <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address r. U.S.EPA ID Number <br /> SAfET?'-hLEEt� SYSTE!1S: 114C (.f.,,7g{: <br /> b{• ., 93TH STREET <br /> Sr?£1+AT!! NTC CA gW,5?a <br /> Facility's Phone: 916-396-4913 CA00G3084517 <br /> is. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containam 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WiNoL 13.Waste Codes <br /> 1. <br /> ,MS WASTE, 3 UTn. DF G DP37 133 <br /> iPJ3'f>tF- <br /> �S BRAVE StLUTION <br /> z 2. <br /> w <br /> U <br /> 3. <br /> 4. <br /> - 14.Special Handling Instructions and Additional Information F'n, t K 003 4- <br /> fi+IXl�1098cT<1-, �� a496c5, , :)370797 0740 25 <br /> 1 . G NERATO-'SI PF R'S RTI ICATID ?Thereby eciarelhat the contemn of Mrs consignment are hilly an"s AS MUESCAPY <br /> d accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I certify that the contents of this consignment cordorm to the terms of the ad ached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(BI am a small quantity generator)is true. <br /> Generators/Olferor's Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Pod of entrymAt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> OTranspo 4 r 1 Pnnted/Typed Name y Signature Month Day Year <br /> Q Transposer 2 Printed/ryped Name `- ig-nature - - Month Day Year <br /> C <br /> F <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Reledon Full Rejection <br /> Manifest Reference Number: <br /> 1 l Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+. Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 1 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> , i <br />