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Please print or> :(t-tvm designed for use on elite(12-pitch)typewr#er:A F'PWY U!'L b'r'21ll Form Approved.OMB No.2050-0030 <br /> UNIFORM HAZARDOUS 1 Generator iD Number 2 Page 1 of 3.Emergency Response Phone4,Manifest Tracking Number <br /> WASTE MANIFESTi s s 1 1 J al S { eft;:� �? 'is 3 0�.20037^ F LE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> istvpl e-lrtland Pliant 0020 <br /> ')80K 1029 444 W Valpico Road <br /> Traatr fiA 95376Generators Phone: <br /> 6. ransporter 1 Compaiany ameP&H U.S.EPA ID Number <br /> lean Harbors L.nvir+ttvtrt!entalSemc:es Inc <br /> 7.Transporter 2 Company Namg U.S,EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ,eat*Harbws kkiltionwioilcsw ty A (3� �(!�7 B Sr« �S <br /> 300 Westtokell Road <br /> Facility's Phone: AG ; ',r%_ t220 r3 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group if any)) <br /> No Type Quantity Wt.Nol. <br /> 1 Ok}#?�lirE,140�r-¢ti�Y RA HAMRDWS 1A ASTE LIDS,(Oil-, r/1j� 352 <br /> Q '1ih7L1'f(CiiCe7 i i_14 r li /✓ - --- <br /> ! �� bAA 1A .200 IA <br /> W <br /> Z 2. <br /> LU9 <br /> 4 <br /> i <br /> 14.Special Handling Instructions and Additional Information ! Y <br /> - 7 Y­�,Ai 11.-x-fG C A 7 <br /> 15. GENERATOR'SIOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and nah'onal 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 certify that the wgfe',fnlnimizatioh statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)is true. <br /> GeneratoeslOfferor's Pnnted,Typed Name S r ignatur i Month Day ear <br /> -r 16.International Shipments <br /> 1- ❑import to U.S. ❑Export from U.S. Port of entrylexit:91 <br /> Transporter signature for exports onl : Date leaving U.S.: <br /> rY 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Rrintedffyped Name Signature ~- on ay Year <br /> Q Transporter 2 Printedffyped Name Signature # ~ •- , ,_ Month Day Year <br /> �/A � �`y /. Lei- �='�L G•� ' ��._Y � C.'[._ <br /> 18.Discrepancy �( <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifesf Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> CJ <br /> Q <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> cn <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prdnted/Typed Name Signature ! Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> lean liasbors acs res apprppinwe°posits III*and atoept thill waits the prterater is smptkitf4. <br />