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Meese prinLar type..F rm designed for use on elite(12-p�■ , ewriter.) � Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOtJ3 1,Generator ID Number 2 Page 1 0( 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST l �' "9- G D F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mallirg address) <br /> IN"IFLRSIXIE IRLKKi,;I:NI(LH t1� P1/�YY`ut7 <br /> R C,1.RC}9d t34f33 <br /> S1OGhTOfd.CA 662(M ;I OCKTON,CA f05206Generator's Phone <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SYS HAZARD SCit_llTIONS C;Allu00641540 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> GE:f►�1-I�Af-#t:�H6)4;%?#�(:�:tV'A,LLC: i:+aLii�l3dF�41 LQ1113551Mfi TE F�fxj: RI) <br /> 0AW40 CORWVA,CA 95142 <br /> Facility's Phone: IR15 351"13" <br /> 9a 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 /> 1- Waste Awr'owft,flarrrtmr"o,(*wh rrotr;"WuIV 4 LC&pocky),2 1, � ow P Dat1 331 <br /> o UN 1 ON,.(DO01) <br /> LU 2. 61A <br /> to 8AWDU$T` IC- , <br /> 3 <br /> . 4. <br /> 14.Special Handling instructions and Additiiona!Information <br /> 1tka1141to deOR7621,Ili%mrrtA6dt?s al$,ERG#1 0 <br /> Gtat.'�PrrAW iVR 1040.ERCT#171 <br /> ApprWista Prratti d"Ctathtft0 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlpiacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if!am a large quantity generalor)or(b)(itI am a small quantity generator}is true. <br /> Generator' Offeroes Printe0yped Name Signature r Month Day Year <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of enlrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials. <br /> LU <br /> cc Transpo tedlTyped Yme ` Signat r Mon Da Y!ear <br /> O 'lJ 1," <br /> a <br /> Q Tran rter 2 PrintedlTyped Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Facility's Phone: <br /> W 18c.Signature of Xtemate Facility{or Generator) Month Day Year <br /> a <br /> z1 <br /> 55 19.Hazardoq W ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> t � <br /> 20.Designated Facility Owner or Operator:;emfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped Neme Si nature -- - Month Day Year. <br /> EPA Form 8700-22(Rev.3-05) Previou editions are obsolete. <br /> TRANSPC}RTER'S COPY <br />