Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Pag mergency Response Phone 4.Hta i°�fest Tracking Number <br /> WASTE MANIFEST l3 p r$ 1 I 1 V :✓ . t. 9 1 F L E <br /> 5 Generalor's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 1-+c �� -4::,- :i rE�Q1l0 <br /> F't r fax 1 Ei2! 4M W V*1C0 Read <br /> r <br /> 95378 TrBCV,CA 99,378 <br /> ?rlti P.;ft-0`1197 ATTN:E-obbip lwnar <br /> Generators Phone: --fl <br /> f-4 <br /> Transporter I Company Name U.S.EPA ID Number <br /> rrr*nW Setvitee tine. M A U <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DesQngdEl( Ndmerd 5ry j U.S.EPA ID Number <br /> W21 Benyessa Road C A U1 0 5 9 4 9 y 1 I 0 <br /> San Jow CA,95133 <br /> Facility's Phone: 1`408'1 44 1 1 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, It,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt./Vol.Wt./Vol. 13.Waste Codes <br /> a <br /> 0M otLU � <br /> ? 2, f#L i <br /> %BSOREIENT) Ob <br /> a .( , <br /> 1tc)o 4 <br /> 1 <br /> 4: t �, CFA S <br /> v/ DF 0oUV <br /> 14.Special Handling instructions and Addifional Information r 5 ,J1.-. r <br /> i. i:Fie3r54+rai/^ .Jr/p .�, 9 qP5 UM <br /> AL1 113 2()9(v 11 3�t4 <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 labeled/placarded,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,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Gene I esJ eroes PriotedlTyped Name igna ure ' , an y <br /> a Year <br /> f <br /> J 16.international Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexlt: <br /> Transporter si nature(for exports onl : Date leaving U.S.: <br /> UJ 17.Transporter Acknowledgment of Receipt of Materials <br /> Trat - 1 Printadl.Typ( aiSign <br /> ignaton ay eare ' 11 <br /> 4 ! <br /> t <br /> a Transporter 2 Printedlryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑T e ❑Residue <br /> yp L1 Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> a <br /> Fadli 's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator( Month Day Year <br /> 4 <br /> Z <br /> td 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I. 2. 3. 4. If <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> P nt,,&Typefl Narpp ! y) Signature Month D Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. i DESIGNATED FACILITY TO GENERATOR <br />