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v\ � <br /> Please rirint or type:(Form designed for use on elite{12-pitch)typewnter.} Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.generator IQ Numb, (1 2 Rage 1 of 3.Emergency Response Phone 4.Manifest Tracking Num�}'b"�er C <br /> WASTE MANIFEST •i�� { ! I•,c....f, t dl e°• lr 'rJ F L E <br /> 5.Generator's Name and MailirlgAddress 1 i 1 t - I",-, ,•!' (Senerator's Site Address(if different than mailing address) <br /> Generaloes Pho e:. t t 3 i' lr ; + J r { ! <br /> G.Transporter i Company Name U.S.EPA ID Number <br /> OAMC'N ll VAIJ ll W-AG'V Ill 01111, <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 /> "1;8R)CIA1 fN:FROAD [-03��riltlil��EI�LdS <br /> 1�"alc i�yt' t� ,CA ti'rx'',,i,"? 20111,84J3-8.18.1 <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)) 13.Waste Codes <br /> No. Type Quantity WLNoI. <br /> 1. <br /> o 1 P+1 ii'�C�::##J "ntl�fAt1i�_PCi R.i ']i,11D 221 <br /> r <br /> LLJ <br /> z <br /> 14.Special Handling InstructionsandAdditional Information <br /> 15. GENERATOR'SIOFFEROR'5 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 labeledlplacaraed,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 I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator s10 oror's Printed/Typed Name SignatureMonth Day <br /> ear <br /> J r�ff���. � ._, ,i,r'L ,•' ;�r`r,/ .r rrr�;'''`,'.-�' t,�" �'� �, <br /> ri i6.International Shipments <br /> f° ❑Import to U.S. ❑Export from U.S. Por#of entrylexit. <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinledlTyped Name rSignature Month Day Year <br /> Q Transporter 2 PrintedlTpped Name Signature Month Day Year <br /> ab <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(er Generator) U.S.EPA ID Number <br /> Q <br /> r�- Facility's Phone: <br /> LU 18e.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1. 2. T <br /> Notice:New federal form. State of <br /> -[I I <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a California requires generator to photocopy <br /> Printed'ffyped Name Signature and mail to DISC within 30 days: <br /> P.Q. Box 400, Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolele. GENERATOR'S INITIAL COPY <br />