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v <br />pleaseD Tint or lype (Form designed for use on elle (12 -pitch) typeWer.) <br />Form Approved, CMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generelor it) Number <br />1 <br />2. Page l of <br />3 Emergency Response Phone <br />4. Man !fast Tracking Number <br />JJ K <br />WASTE MANIFEST <br />i. Generator's Name and Mailing Address Generators S le Address (d different than maitng address) <br />Generabts Plane: <br />6. Transporter 1 Company Name U.S. EPAID N,T.ben <br />FP$'irtGl9Pir`EY _. <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8, Designated Facility Nrlleard Ste Address U.S. EPAID Number <br />HAN',CAL WA9TE WMA GFk*0'T <br />5i'Tl1 rtt.r] N Yl M[F Fer, <br />i:ET!LEMi D7-. CA 9S's'3) <br />CAT 6 0 0 8 4 8 1 1 7 <br />Facdnya Prone 5 9,t3c*"1 <br />8e <br />9b. U.S. DOT Description (including Proper Slipping Name, Hazard Gass, ID Number. <br />10 co'smind <br />11, Total <br />12. Unit <br />13 We. Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quandt <br />"N"'o'.1. <br />K <br />M2 <br />o <br />qa <br />!e <br />P <br />z <br />2. <br />3. nn als <br />14. Special Hard, instructors and Additicnal Information <br />15. GENERATOR'S10FFEROR'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 />marked and labeletlloacarded, 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 EPA Acknowledgment of Consent. <br />I tartly that the waste minimisation statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (ifI am a small quantity generator) Is live. <br />GeneratoeslO9enofs Printed7Typed Name Signature ', Month Day ' Year <br />J <br />16. international Shipments <br />❑ Import to U.S. Export from U.S. Port of enbyiagt <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. TmnspoderACODWedgment Df Receipt of Materials <br />Transporter 1 Prinled,7yped Name Slgna:ure Mordh Day Year <br />a <br />QTransporter <br />2 Printed7ryped Name S;'a'ue _. Month Day Yew <br />r <br />18. Discrepancy <br />18a Discrepancy Indication Spam ❑ OuanYq QType ❑Res due ❑Partial Rejection ❑Full Rejecden <br />/. Manifest Reference Number <br />1 b. Alternate Facility (or Generator) US. EPA ID Numoer <br />J <br />U <br />sa+. <br />Fadfitya Phone: <br />W <br />18c. Signature of Alternate Facility for Generator) <br />Monty ay Year <br />H <br />19. Hazardous Waste Report Management MaMod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />20, Designated Facility Nvi or Operator: Cergficin on of receipt of hazardous materials covered by the manifest except as noted in Item tba <br />dntedrlyped Name _ Signature 11n1h Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous ed]Wns are obs01ete. DESIGNATED FACILITY TO 7'=" <br />