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s <br /> PIeeS'€print or type. Form designed for use on elle(12-pitch) <br /> UNIFORM HAZARDOUSx Forel Approved,OMR No.2050-003 <br /> 2.Page 1 of 3. <br /> WASTE NIFEST Emayenry Response Phare 4 ManHasl inddng Number <br /> MA ./ Id;" JJK <br /> 5.Generator's Nemo and M1lailing Atldress - 007926838 <br /> C Oerremtor's Sile Address(ddl8erent than mai0ng address) <br /> PWo,(Ac rniCc� f Dora}lcn ttYa clif-r LAS <br /> 0%. LctylSi fl cue. b ilW ,4 E` <br /> Generators Phana: f1 Is C t...f.Q, " tsL+' r• f <br /> 6,Transpolar 1 Cumpany area _ _"R <br /> U.S.EPA tuber <br /> q <br /> 7.Tr�asp40er$Cy�pppy pp fi iq C�.../�!'-(}oon <br /> fjj U.S.EF I <br /> B.Oe,�leyFnup(Y Rg38iMAtldrex,t?,y- .. .. <br /> 6012F HAY RO,ACt - - - - U.S.EPA ID Number .. _ <br /> VAGAALLE,GA x8507. a"Q' <br /> FadliVs Phone: 707-151.32eh' <br /> its. So.U.S.DOT Descrgb'on Including Proper Shipping Name,Hazard Gass,ID Number, <br /> HM and Paddng Gmup(aany)J 10.Container; 11,Total 12.Unit 13.Waste Cotler <br /> i{ Ea�'ti;k, <br /> 1. Fi.0 RWNo. Type Quantity Wtivol. <br /> ¢ L' �,fitK lc'S:,F'tiPd <br /> Cbk 53 .. <br /> rZ 2. <br /> 3. <br /> 4. — <br /> 14.SQeda.aI Handjinty,mstrbcvobe and Additional InlormaUon <br /> mc- O5 KF3,4L"r.4U.kEr;g'.'R�+�E.M dOCFfiS± (19AGGEB, SEA;.EO, i LABEL,Et7j 6;3D•12R5p3r . . . - <br /> FRIA6tA� t,e_ F:51'6S COMAill- I"71 rAt MAERG 0171) T•t View 3108 W. cAPiFOL .AYE, W SACFtk10 TOS CA 95631 <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATIFP:: Thereby dechm that the currents Of'this wrsiumrt Ara,elryanti awumlely tlesaibed shove by the proper shippingname,aMare cMssified,packaged, <br /> marked and Iabeled/plocamed.and ere m all mapece in proper consul for sampan aco d rq b,pplhaba In[Inmlionaland national gavemmeby t e Prop r Ah If export shipment and and I am ma primary <br /> Exporter,I wrdly mar the wntenls"is consignment conform to me tams of the al@Ched EPPAckwMedgrtnnt of honaent <br /> I certify that ma waste minimization stalaman[Identified in 40 CFR 252.27(a)Of am a large bill generator)or(b)(dl am a small quanU <br /> Ganeretors/Oaerofs Pdmedrryped Nana tygenereto0 u tree. <br /> Signature� Month Da 4.a .7� -7y�e;.., Y Year <br /> 76.Inlematlonal ShipmenlsF "� ^�'� ryy �� ! <br /> ❑Impwtto U.S. <br /> T ❑Exlwn ft.U.S. Pon of ant /exa:Transporter signature(for exports ony): ry <br /> K 17.Trens Date leaving U.S.: <br /> w porlerAdmoxkd dRecelptof Marorials <br /> yam. TOO 1 Printed/f In <br /> h ,� ` '. SignaWre Month Day Year <br /> Trersporter2 PM ams '`� r j y{. <br /> h y' Month Day ear <br /> 1 18.Discrepancy <br /> 18x.Discrepancy Indication Space <br /> .. _ ❑ OuenUty ❑TYPe ❑Resitlue ❑PsRial Rejection ❑Full Rejection <br /> 18b.Alternate Fadliry(or Generator) Man'Rest Reference Number: <br /> U.S.FPA IO Number <br /> U <br /> LL Facaitys Phone: <br /> 18c.SgnatureofAllamete Fadlity(or Genemmd <br /> 2 Mordh Day Year <br /> m19,Hazallous Waste Report Management Method Codes(Le.,modes for hazardoua wads u9shent,disposal,and moyding stratum) <br /> w 1 <br /> 2. 3. 4. <br /> 1 20 <br /> PnmDedsTyignpeed Name <br /> Own.a.r+oJr O <br /> pe a or.Ca tl ration o rew° p(teiha amour ma a als co Bred breae <br /> Sigrreure `F � Mynm. Day Year <br /> res,, ...._-,.. ..�.-^ t 1` C + �,•,a..... �'d"i.�, - �:..s '� p <br /> EPA Form 8700-22(Rev.3-05J Previous edlUons are obsolete. <br /> DESIGNATED FACILITY TG bENERATDR <br />