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Pease print or type.(Farm designed for use on elite(12-pitch)typewriter.) tl:=? Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS1.Generator ID Number 2.Paige 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 1',09 4 9 ¢ 0 Gi. v 1 F L E 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) 4001 '.VV40co Road 1 �ti��lRg't!�talli Okllx�1 Generator's Phone:"i "f TracyFCA 06376 6.Transportor 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 11021 BWrOgi f Cod Ran_kow,n.jk 05133 Facility's Phone: 1 4 r ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes y No. Type Quantity Wt.Alol. � 1,�+;'�*�>r•.�4�_?�r��i�'J��'��l_:��.��T�41.�ip�� 14.A�_�i�r` � 4 _ Z 2. W 3. 4, 14.Special Handling Instructions and Additional Intcrmation a 15. GENERATOR'$1OFFEROR'S CERTIFICATION: l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable intemabonai and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generato s eror's PrintedlTyped Name Signature ont! Uav ear 16.International Shipments � ❑Import to U.S. ❑Export from U.S. Port of enkrylexit: Trans ortersi nature ifor exports cri : Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name SignatureMonth ay ear QTransporter 2 PrintedFryped Name Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Typ e ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V Q +L Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 24,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnntedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY UNM Itilliebum halls time al-VraiInillaft pumlift fxfs arwd,W41 aecaqt4 ttse W&W.0 thv-.44Wft&tsa^ar im•al7o"s"