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Please print or type,(Form designed for-use on elite(12-pi writer.) Form Approved.OMB No.2050 0039 <br /> UNIFORM HAZARDOUS 1.Generator to Number 2.Pae 1 of 3.Emergency Response Phone 7d6—Tracking Number <br /> WASTE MANIFEST a r <br /> 0 <br /> Jr 0 131 2 3 5 115 4 21 JJK <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> I N f'EVI I I AIL tR1KKCF`N1EP <br /> ti 1325 IktAV'ii <br /> "A KIM. C)k 04-NA S1 OCKTM4,CA 95206 <br /> Generalor's Phone: 1100 314 4563 <br /> 6.Transporter 1 Company Name U.S.EPA iD Number <br /> �J; i JAZARDE;(;OLIJIONV, <br /> 7.Transporter 2 Company Namo U.S.EPA JD Number <br /> 8,Desl9nated Facility Name and Site Address U.S.EPA to Number <br /> (A',"M RMCW)CORDOVA,W." <br /> 11055 MITE r40CK RO- CAD9800144193 <br /> RANCtl[0 C.0fZD('.)VA,CA 05742 <br /> Facility's Phone: 91(J-351_09W I <br /> 9a. gb.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 WL(VOI. 13.Waste Codes <br /> 1, VVOS1.0 OXTOO(Niq I L C VauiN),2 1, <br /> 0 1.4410150., P <br /> Z 2 nlf'ff! {:{ #1­152afclous W90.0 Solid, -kart sui F' 12e1 <br /> LU <br /> 352 <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> Apriropria[n POA00"00trinq <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 /> I marked and labelodtplacarded,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 onnslgnment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste rnlnlmizaUon 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 We. <br /> Generatoes/Offeroes Pdr(ed/Typed Name Signature Month Day Year <br /> _j 16.Intematonal Shipments <br /> I— D Import to U.& ❑Export from U.S. Port of entry/exit: <br /> 9 1 Transporter signature(for exports only): Date leaving U.S.: <br /> L= V.Transporter Acknowledgment of Receipt of Materials <br /> Li <br /> E2 Transporter I Printedf7yped Name Signature <br /> 0 ? Month Day Year <br /> co <br /> Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> u- Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month <br /> Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU1. <br /> 2. Notice:New federal form. State of <br /> California requires generator to photocopy <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18; and mail to DTSC Within 30 days: <br /> Prinled[Typed Name Signature P.O. Box 400, Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />