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Please print or type.(Form designed for use on elite(12-pitopewdter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST . . <br /> ( yafv`:- �. F G B F <br /> 5,Generator's Name and Mailing Address Gen r' e Addee(if different Man mailing address) <br /> JMC4.-NF'MENTC0, MAi•tTEf,.A <br /> 321 SWILCkElui ANT] <br /> RiA Ict A,CA okl:1r; <br /> Generator's Phone:Compa' im <br /> fi.Transporter 1 Company Name � U.S.EPA 10 Number <br /> swi*NA,LttNGaS£a_rli.lTlc: i.HN:. E?N.1FR.NW48:JS97 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number CEMR ATEyC .I.,PDl9,UC fi�rdi+.fitlf�f <br /> I t656+Af}�NTF PrXP;RD <br /> I?tg4c:WiCOPOCI+/A.CA iA742 <br /> Facility's Phone: 916-351-tly .[ <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt N01. <br /> 1. f♦ru�FR I-Vi.r.ARDtILISWAS FL54-'NJfY rA4 405 P 223 ! 3,.S2 <br /> o (A <br /> Z z. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> F'kflLk-Nt IRM3.1lt?00 <br /> AF1PfTC1F1RA rE PT4o)fC-LmvE-C-1-01H1,113 <br /> ':E1: F p(;5111 EWNGE.N0 CONITAC I 5 <br /> •\ r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are(LrOy-ihcfadcuraTelfdes—cr[bd8-aiUol:vl6 by the proper shipping me, areGie ,p kaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and am theZmany <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I cattily that the waste minimization statement idenlifed In 40 CFR 262.27(a)(N I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneatorsrOBemr's rintedrryped Name Signa '/"I " Month Day Year <br /> r r <br /> 1 .International Ship is // - <br /> p_ ❑Import to U.S. El Export fromm U.S. Po of 8hG/lexi[ <br /> Transporter signature(for exports only). Date leaving U.S.: <br /> C 17.TansporterAcknoWedgment of Receipt of Materials <br /> UJI <br /> Transporter 1 Pr'ntedRyped Name Signature Month Day Year <br /> a j - <br /> Q Transpomerff Art NameSI ! o y r <br /> n: <br /> r <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ElType ❑Residue ❑Partial Rejection ❑Full Rejecli0n <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA 1O Number <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 6 <br /> z <br /> y19.Hazardous Waste Repos Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> coo 1 z. 3. Notice:New federal form. State of <br /> California requires generator to photocopy <br /> 20.Designated Facility Owner or Operator:Certi6cae0n of receipt of hazardous materials covered by the manifest except as noted in Item 18, and mail to DTSC within 30 days: <br /> 1 Prinled7ryped Name signature P.O.Box 400,Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />