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Please print or type.(Form designed for use on elite(12•pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.GenemlorlD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number y <br /> GBF <br /> UNIFORM HAZARDOUS cm3'6�'i} Vii,-T��,�'1�9E"'( ( !�t <br /> GBF <br /> WASTE MANIFEST <br /> 5.Generetods Nameand MatingAdd,,$KM on F'MT']M RE�5 Generetor's SlteAddress(ldifferent then mailing address) <br /> (209) gSOU cL.ALJSRP.BL•D016, STTE 12. <br /> Generemrst bllel'�f$ g R'tt BA2k� .' CA 9536? U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> F•_ p_Nff OfL FILTER RECS' UNG h*3469 G (in;ls JC�.2 <br /> U.S.EPA ID Number <br /> 7.Transporter Company Name <br /> B.Designated Facility Name and SRO Addre s U.S.EPAID Number <br /> .'L't�.ttl OIL 1"G.. <br /> ' %.I+t5F�1? <br /> ()09)rl 53tx)c AUS RD. SLD03I? t:, Lf?OOt90ctFy <br /> Facility's Phone -sl O! .f5-��i� .3'MNrsa CA-9fi367 <br /> 9b.U.S.DOT Descdplon(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.70121 12.Unit 13.Waste Codes <br /> HM and Packing Group <br /> iifany)) No. Type Quantity Wt./Vol. <br /> K 1. pON-nyCAY <br /> 01, T1 <br /> Z 2. E 1 <br /> fW9 <br /> 3. OC 16 015 <br /> 4. NVIR Nth! NTAL <br /> IN. n9:04 a1�A1'r <br /> 14.Special Handling Instructions andAddidonal Information <br /> 6t E312 <br /> oy.ova ERCT !?t <br /> 15. GENERATOR•SfOFFEROR'S CERTIFICATION:Itnereby deciere Wat the contents of this consignment ale and-wratetydesaibed above by I* Werstippngnama.adaredassdied.P8*ag4 <br /> marked and labeledfplacarded,and are in all respects In proper condition for transport according to appIkobie intemallonaland national govemmentel feWW .oexport aro I am he PnFxary <br /> Exporter,I certiythat the contents of this consignmentmnform to the terms of the attached EPAAcknowledgment of Conal. <br /> I certify that the waste minimitabon statement identified In 40 CFR 262,27(a)(if l am a large quantity I'm <br /> ereNr)or(b)(glam a small quantity gaeabr)s hue. D" � <br /> Generatorsl0lfem_fs Pdntedrfyped Name SignNre <br /> F 16.Intematlonal Shipments ❑Import to U.S. Y ❑E>q:atirom ILS. PatoferntypAsk <br /> Z Transporter signature(for export only): Dataleanng US= - <br /> 17.TmreporwAcknowledgment of Receipt of Materials _ bk,* � ffi <br /> Sgnan e <br /> kj Transporter 1 PrinteMyped Nam <br /> GTransporter 2 Pdnted7ryped NameSigna Yat+ lir <br /> ad <br /> f <br /> t18.Discrepancy <br /> 180.Discrepancy Indication Space ❑ quantity ❑Type ❑Resbm ❑� ❑� <br /> Manifest Reference Number. <br /> r 18b.Alternate Facility for Generator) U.S.EPA Y7 Ptr.CEr <br /> J <br /> v <br /> LL Fecliys Phow: MIX* OR yaw <br /> W Iso,Signature of Alternate Fedlity(or Generator) <br /> Q <br /> Z <br /> S2 19.Hazardous Waste Report Management Method Caries(ie.,Ades for hezardaus waste treatment,disposal,aid nayd'ng system) <br /> 4 <br /> 2. <br /> 3. <br /> 20.Design FeaMy OwnerarOperetor.Cedifiation of receiptot.hazardous materiels covered by the manifest excepfas noted in Ilan 18a <br /> 1 Pdnteffyped Name i J Signature <br /> EPA Fomn 8700-22(Rev.3-05) Previous editions are obsolete. v <br /> GENERATOR'S INftIAL COPY <br />