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.S: <br /> Ay '� <br /> Please print or.type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UN1jFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number p <br /> WASTE MANl6E5T )AE A 1 'a �81�f U"103434180 G B F <br /> 5.Generator's Name and Mailing Address "F "Gene�afar s Site'Addiiess(if different than mailing'address) <br /> Generator's Phoni[W12-55W DICK f�A 9621% <br /> fi.Transporter 1 Company Name U.S.EPA ID Number <br /> £tt41.S:3L:'M `„tfAKM Oill..lit K, C<#tFMf:tLXr.112Wj <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> :a1 E.kK,"(CLL 'iMOIAL 14 UU'A,M;. }3.1,31 �f�#3, ft+d h1n3f.1f OIt 1t.1 24 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GH-'giICAI ttEL:4 k1fR19t t aY€:a T7Ci'yf vJt34�31C4t <br /> ryl VOWELL I fit#Cfi <br /> AV.AWN,N,TY 7662'7t <br /> Facility's Phone$/,�'i`tM-:'224 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> t 1- ?'4Ca_€A`i1f�(o3.jVA.Stt- t S..�tivkhi7,r l.k i.1C.1 ILY6,�!�'3. . :% Yk_af3 :i [f t tft5 ;g €3)Yf1 F=0M1 244 <br /> ours --moo*1 <br /> w <br /> z z. <br /> L <br /> A <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> F'it(.1A tL i;:Af 117iARv J 1 .!-'Ah w§ * f#r ;JFiW4 i za <br /> APPFi4VRiAl t4k01'EC'fNj,-- t.011,11f 10 <br /> f kC.IFii(:Y (,tAjIAt;f-'ff."Xj ft:jh <br /> 15. GENERATOR'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 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 I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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(bt{ff 19m a small quantity generator)is true. <br /> Generatons/0ffem(A,,{jW1Wi Cypeedd Name ijl Signature f Month Day Year <br /> 1 -71 <br /> F 16.International Shipm nts <br /> F- El Import to U.S. Export from U.S. Port of entry/exit: <br /> ❑ <br /> ?=" Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed(Typed Name Signature Month Day Year <br /> 0 Sr <br /> zd Transporter 2 Prmtedrryped Name Signature Month Day Year <br /> r <br /> n 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C7 <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Dov Year <br /> 4 <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Notice: State Of California requires <br /> generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18 DTSC With 30 Gays: <br /> Printed[TypedName Signature P•0 BOX 400 <br /> AI Sacramento, CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />