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w <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />t <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />I <br />WASTE MANIFEST <br />JJK <br />Ge,erabrs Name and Mating Address Generators Site Address (if different than mailing address) <br />Ceoeretors Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name US EPA ID Number <br />8, Desop @led Faclt, Na me and Ste Acdress P "'"'�'�{, U.S. EPA ID Number <br />go` <br />Fa- y's Phone AUG 0 2 <br />a <br />9b- U -S DO 0 Ic-. '. a F'cpe' S, -.g Name, Hazard Class, ID Number, <br />10. Containers <br />11Total12. <br />UnitW, <br />arc Pzeno Group h�a=yr ¢ <br />Quantity <br />Wt %1 <br />13WasteCodes <br />No. <br />Type <br />K <br />L F1r <br />Oof <br />-- <br />of <br />w <br />Z <br />2 <br />Ulu <br />1HIS WASTE STREAM HAS BEEN QUALIFIED <br />FOR RECYCLINGITREATMENTS AT THE <br />— <br />DeMENNO / KERDOON FACILITY IN COMPTON, <br />CALIFORNIA. THIS FACILITY HAS THE NECESSARY— <br />QUALIFIED. OUR EPA NUMBER IS CAT080013352 <br />—�--�— <br />' Soecia'Hane ng nstructlons and Addri In <br />T <br />p�� <br />-+:.i'CFt51fd?4d4YSEAN t'SPv' WA -1r <br />2A tiff ERK°Rc,-'ENCY CONTACT:. ENY ffi e:-Fi l <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above "a pros shipping name. and are classified, packaged, <br />marked and labeled.rplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If eglort shipment and I am the Primary <br />Exporter. I certify Nat the contents of this consignment uniform to the terms of the attached EPA Acknowledgment of Consent. <br />I certity that the waste minimization statement identified in 40 CFR 262.27(a) (R I am a large quantry generator) or (b) (II am a small quantity generator) is true. <br />GenerstoevORerors Pnnted7yped Name Signature Month Day Year <br />J <br />16. International Shipments <br />PI Importto US. ❑Export from U.S. Port of entrylexh: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />� <br />Transpo^.er 1. Pnnletl:Typed Name Signature Month Day Yea, <br />O <br />`0 <br />N <br />M <br />Q <br />Transponer2 PnntedTyped Name Signature Month Day Year <br />x <br />f <br />18. Discrepancy <br />18a. Discrepancy lndiw6on Space ❑ Quant ❑T a El Residue Partial Reec@on <br />Quantity yp j ❑Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Fadlity(or Generatoq - U.S. EPA ID Number <br />J <br />U <br />LL <br />Facddys Phone: <br />w <br />led. Signature or kemate Factoty(or Generato0 <br />MonthDay Year <br />Q <br />Z <br />t^ ' 9. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyclng systems) <br />--T-- <br />2. . <br />4. <br />edFacility Owneror Opera or Certifficalon of recepto(hazardous materials covered by themanfeftexcept asnoted in Item 1 B <br />1 <br />'ped Name Signature Monty Day Year <br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obso�ete. DESIGNATED FACILITY TO GENET TO <br />