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tUN1F0RKKQV*0US <br /> pe.(Form designed for use on elite(12-, ..q M*wrtter. Form Approved.OMB No.2050.0039 <br /> r�l' 1.Generator ID Number 2:Pape 1of 3.Emergency Response Phone 4.Manifest Tracking umber <br /> MANIFEST C A 0 9 6 0 a e 8 8 1 1 y, 6p0-535-589003512487 JJK <br /> u Ram and Malting Address Generstor's Site Address(t different than mailing address) <br /> 8 Ll AIIf <br /> COMI? '? 17ORP. <br /> 1419 WAVY upi V <br /> MrK'T'0110, CA 95266, <br /> Generator's Phone:- - <br /> 6.Transporter 1 Company Lie U.S.EPA ID Number <br /> WITVAR TiSA ItiE . C. A ll 0 1 0 9 5 5 7 6 <br /> 7.trinspottet 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fadllt die end Site Ad cess U.S.EPA ID Number <br /> 1�� SAN r) <br /> tis�A �ic�cr <br /> SAW rami CA 95113f A w td 5 9 l 3 1 i3 <br /> FadWs Phone: 62 <br /> 98, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> 11,Total 12.Unit 13.Waste Codes <br /> HM end Pnddrhp Group(t any)) No. Type Quantlty WtNd. <br /> I.NOIi-1lC.kA, KX2kP D<XfT1 WASTE, SOLXD <br /> J 6MK6'TY £tP.hiDtl Y "�1 . <br /> Z 2. <br /> W <br /> n <br /> 3. <br /> t , <br /> 4. <br /> • <br /> 14.Special Hand Instruc8oMm andAdditional Iniamation <br /> 1,.. CM3 O083 <br /> PLACARDS PWA111 DED $X CARRIER/523I PP R IZS/W) DRIVER 5I GNA,"1'tfl E <br /> *►* XPL CALLM NNT YISI ]rT UNIVAR ;TSA AS I"GMSTRhVT *#,*it. G 8f0FFER0R'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,padutged, <br /> marked and(abeledfplacarded,and are in dl respects In proper condition for transport according to applicable intematlonal and national govemmental regulations.If export shipment and I am the Primary <br /> Fpoft,I owlify that the contents of this consignment conform to the terms of the attached EPA Admowledgment of Consent. <br /> d cor*thMdhe minimization statement Identified in 40 CFR 262.27(a)(t I am a large quantity generator)or(b)(t I am small quantity generator)Is true. <br /> Geer"ta Name Signature- ) MordYear ay <br /> t-. 16.In Stdpments ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Transporter signabu•.(for exports only): Date'leavkg U.S.: <br /> 17.Transporter AdmmNedgrrreM of Receipt of Materiels <br /> q Trettsportar i Name Signature - Y Year <br /> f/ <br /> ✓'7 .,� e ''."moi •..� `�.'" .,.. <br /> Transporter 2 PrintKVTYW Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indlradon Space ❑ Quantity ❑Type' ❑Residue ❑Partial Rejection ❑Full R*ction <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Fadlitys Phone: <br /> W 18c.Signature of Altsmate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes forhazardous waste treatment disposal,and recycling systems) <br /> UJ 1. 2. 3. 4. <br /> 20.Designated l'adlity Owner or Operator.Certffkatlon of receipt of hazardous materiels covered by the manifest except as noted in Item 18a / <br /> Printed/Typed Name Signature ^ Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> r' <br />