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Please print or type.(Form designed for use on elite(12 pltchtovnter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number ,:..5 i gr- 2.Page•1 of 3.Emergency Response Phone 4.Manifest ThaackQing�N+u6377 <br /> tier <br /> WASTE MANIFEST Q V 6$©6 3 7 7 FLE <br /> 5.Generators Name and Malting Address - Generator's Site Address(it different than mailing address) <br /> Wine diri.1 ini.: - <br /> 001 F ie,ate kiailf"rwa,,t 1C"4'I <br /> i;,.-INVA "3..1,'ii 6- <br /> Generators Phone: <br /> 3 GeneratorsPhone: 22151- <br /> 6 Transporter 1 Compan ,ame L_ r-T-p� ,-. U.S.EPA ID Number <br /> 9, INC. JUL 02016rYliio7,,. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ^ xr M5� ' <br /> 8.Designated Facility Name and Site Address i,;L t" ' 1 td 1i.StJ123 :iliAf ,7v`:e LL.',: . . umber <br /> SAN X15i: CA 95'1. 3 <br /> Facility's Phone: <br /> go. 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 WWol. 13.Waste Codes <br /> x 1 'tjitiii��(11q tJF1'=�i r. fr� T!-ii:pvl (•' l)i`f •V,(Q" ii'+ <br /> W2. 1]Njv, NFIN--Ri"g;1:i t'i 'Li? cL} '.i iV:"1; F, <br /> r, t'LisJl T1€ 1 , N'/A <br /> 3 NONE hf hM F?Gh+1 H:q,7777;73 !fi` 77 651r. 1 <br /> ff.Rqmx [ ltPeTtOmilki in, tdi lFA nil I, td:':- 5 <br /> 4. <br /> 14.3pecial Handling Instructions and Additional Intonation <br /> 1l�"�`•�'1,Sin <br /> ?4 1 FINFAISEMUY 43K / IFT` <br /> n i� , Tri. rf C'^. <br /> pdfH q.; fk ,i_P�T..a � kvt.Jd 1 R, i�TN <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the pmper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemabonal and nabonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I ceNfy that the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent. <br /> I cerfify 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 /> enerato ernes Printed/Typed Name Signature on ay ear <br /> ' 1 <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Expon from U.S. Pon of entrylexit: _ <br /> Transporter signature for exports only): <br /> Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials j <br /> Trjznspo(Mr 1 PrintedRyped Name Signature Monthay Year <br /> H �` }'f 'yL. ..t v Y1 r L.•J I .�... J.'4._ '1 4. <br /> QTransporter 2 Printed/Typed Name Signature cant I Day ear <br /> K <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue ❑Partial Rejection <br /> El Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> a Fa- sPhone: <br /> 18c.Sgnature Of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 2. 3. 4. <br /> D ' <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.: t ct169 W;7 0?,6 7 9 ,� , , ;:k't*,� GENERATOR'S INITIAL COPY <br />