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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OM®No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST U iw 134390 G B F
<br /> 5.Generator's.Name and Malling Address Generator a'Sit`e A dress(if different than mailing address)
<br /> f3KEWER
<br /> Generator's Phone' 41...yrt,4;
<br /> 6.Transporter I Company Name U.S.EPA ID Numbers
<br /> AMVr 1YW VAI,L lh,'q -WA, It Oil-M.
<br /> i Transporter 2 Company Name U.S.EPA ID Number
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<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> 21;s1 k:4-J%l 11 Lht Y hF^Wit'f-44W'k4IPit, io4i,Wi lett- NLVA#..,tt.t ;i,^"+°sfts?�s1i:5 tf1
<br /> tAl %,04 i;3
<br /> Facility's Phone:i t�-
<br /> ga gb.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10-00 1t.Total 12,Unit
<br /> HM and Packing Group(if any)) No. Type Quantity Wilivol. 13.Waste Codes
<br /> 1. _,. ,
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<br /> 3. 11, (ltd I1A5 WASTE F IAWMi_AL1- J-(10i.OFtl'„+�,IC,i'V 0 et,+1.I, 3 014 ce s::i Mo 3-+'
<br /> f-16V#', ill.X,k'J:STEJJ AJC1X)ijj'II9rS+WI-1i-1l#Z+�f i.Peel:)r ; .Yfl1 -
<br /> 4.
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<br /> 14.Special Handling Instructions and Additional Information
<br /> a 'I t' diig'i:f:l t dvbl i ;,aEkilt,7 oriel f I tt df 9'.t jo-,V,:,WiJ(J?�J-k;n FIrL 104 GAKE It Rf-W i 3 -,
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<br /> 15. GENERATOR'SIOFFEROR'S CERTI FlCATION: 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 labo dlplacarded,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 identiffed in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if I armea small quantity generator)is true.
<br /> Generator'slOfferoes Printadfi ed Name t Srgna" Month D y Year
<br /> 16.Internationale Shipments
<br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit:
<br /> Transporter signature(for exports only): Date leaving U.S.:
<br /> LW 17.TransporterAcknowledgment of Receipt of Materials r i
<br /> Transporter 1 PrintedfT-ped Name r Signature / Month Day Year
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<br /> Q Transporter 2 Printedrryped Name Signature Mon ay Y ar
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re
<br /> yp Rejection J ❑Full Refection
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> J
<br /> U
<br /> LL Facility's Phone:
<br /> - 1
<br /> LI 18c.Signature of Alternate Facility(or Generator) 7th Day Year
<br /> Q
<br /> Z
<br /> v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> LU 1. 2. 3.
<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 18a DTSC with �days*
<br /> Printedrryped Name Signature
<br /> P.O Bax 400
<br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. Sacramento,CA 958 .2-0400
<br /> GENERATOR'S INITIAL COPY
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