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Please print or type.(Form designed far use on aide(12 itch)typewrite,) <br /> UNIFORM HAZARDOUS 2.Page I of 3.Emergency RForadesponse Phone 4.ManReat Tracking Num prosw SNo.2050-00 <br /> WASTE MANIFEST C A 1, 0 0 0 2 % 1 6 0 4 <br /> 5.Generaaofs Name and MaiChgAddress ��� td�.^064730 JJk <br /> '�aea'i+Y«4isiatbDey A DiF1`dO8 F10Ta111'p•Genemlofs Slfe gtldress Qf diflerant Oren mailing address) <br /> 1010Ifirkr4�f1a,!Orw <br /> v� <br /> St4Wi CA <br /> Generatofs Phone: 2 G 9 t <br /> 6.Transporter)Company Name <br /> 6'9*' Hn(mss)4"4ERI NONE•.bus!.iG:&75C ek7D�"'3 u.s.EPa IDNamcer <br /> 7 Transpo1er2C0mpany Name C' C 0 k 7 8 7 4 7 <br /> MiYi EfIvrim lmEtl`Fl+,T81V 5 U.- <br /> 8 <br /> .S.FPAID Number <br /> 80esi oared Fadlity theme antl Bhe Address C. A d 8 <br /> 101 _ " U.S FPA IO Number <br /> 791 South k'eIk GNlYF <br /> ha P-'S" Tk TN 58474 <br /> Facilitys Phone: 931 $M 9642 <br /> ga. gb U.S DOT Descripfion(induding Proper Shipping Name,bh wd Class,ID Number, T N S & 1 ' 2 C 1 1 g <br /> HM and Packing Gmup(f any)) 10.Containers 11.Total 12,Unit <br /> 1� n RCRA i Yzaa+DiFa , IFLt Na. Type Quantity WVVaI. 13.Waste Codes <br /> ° h ;r <br /> fly' F 181 <br /> � <br /> ac <br /> w <br /> 3. <br /> 4. <br /> 14.Spetlal Handling Inslmcdons and Additional Intormalior 11, , 1 / . . rJt. <br /> 15 GENERATOR'&OFFEftOR'6 CERTIFlCATION: Thereby dedere Nat Ota contents olNis censgnmentare Nlly antl eocumtery des....above by Ne proper shipping'rlam�aM are dessMed,packaged, <br /> .%mafred and lehel)(110-carded,and are m a6 map.=in pmPer caMilion for transport according to applicable miamaliorreland national governmental regdations Ifekpartshipm¢nt and I am the Primary <br /> Exporter,l,entry that Ore contents of Ws consignment conform as the terms of Ne atladted EPAAclmcwledgmenl of Consent <br /> I ceNfy Nal the waste mimmvatian statement identified in 40 CFR 262.27(a)(If l am a large qua^ally generator orb ifI em a small quantity <br /> GeneretofslORerofs Pnnted?yped Name ) ()( q IY generator)is tare. ' <br /> � <br /> r SipnaNra <br /> ,rrJ 'Yl s MmN qaY. Year <br /> 16.Intematwnal Shipments ,G. r :� . f•e":,.•;`.,-.:' „! -n; .,,,.'�:,. T' f 6 Sr. <br /> ❑Import to U.S <br /> ? Transpuner agnature(for mons only): LJ Faporl from as Port of entryf'.k. <br /> W 17 TmnsporterAcamowledgmed of ReceiptofMaedals Date laavmg U.s' _. r <br /> K Transporter 1 PnMedR d Name <br /> Y/Q�a Signet <br /> �44 .. ._- Month Day Year <br /> /�y'22 �F <br /> Tmnaporter 2 Phnled(Typed Name <br /> Signature <br /> I,I, ., J/.. ,.^""'J Month Day Year <br /> 16.Discrepancy '"_ �'.c' c' .m^^`.•� o� .�C/ <br /> 18x,Okcrepancy lndMaaon Space <br /> ❑Quantity ❑Type ❑Residue <br /> ❑Penial Rejection ❑Full Relectien <br /> 1 S,Alternate Facility it,Generator) Manifest Reference Number: <br /> rj U.S.EPA ID Number <br /> LL Facility's Phone' ' <br /> w 18C. ignature ofAllemate Fatlliry(or Generelw) <br /> x4 Month Day Year <br /> N19.Hazardeug Waste Repon M1fanagement Mebwd Codas g.e.,codes for hazallous wesk treabnent,disposal,and recycing systems) <br /> 1 20.Designated r,ciety Owner a OPaird-1 Cartliccation of receipt Of hazardous maedals covered by Ne manifest exceptas noted In Item in <br /> fnled?ypad Name <br /> Z' Signature fr - <br /> Monty fray Year <br /> EPA Fun 8700-22 (Rau.305) Preyfous editions are obsolete. p/ �; '.�•'%�!� f� j f`� /`.: <br /> DESIGNATED FACILITY TO GENERATOR <br />