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ease print or type.(Form designed for use on elite(12-pooh)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFOR L AZMOOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A 0 9 ® 0 0 & a 8 z r i >a00—535—S$sa1 003512487 JJ K <br /> 5.Gererator's Name and Mailing Address Generator's Site Address(ri different than mailing address) <br /> 9I LOAN COMM? CORP. <br /> . <br /> 191b NAVY DR116M <br /> (X.'RToV, (,A 952116, <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> LINIVAF 11SA I101' . f_' AUC+ 1 0 9 5 5 1 6 <br /> 7.Transportar 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name-iii Site Address U.S.EPA ID Number <br /> CLEAN IbV4 MS SAA JOSE <br /> 1021 E32RYES 5A ROQ1ra <br /> SAN aM, CA 95133 <br /> C, A tI 5 9 4 9 4 3 2 <br /> Facility's Phone: 01492 <br /> 9a. 9b U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Confadne►a <br /> HM and Paddng G-p(ff any)) 11.Tafel 12.Unit 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 1.N0*-1k(–IkA HAZAAix1UG WASTE, SOLIrr �+F <br /> z 2. <br /> U.11 <br /> n <br /> 3. <br /> 4. <br /> • <br /> 14.Special Handing Instructions and Additional Information <br /> PLACAR@S Fri 1 Di:L1 BY CA.RRI ER,'SHI PPER Ur S i'11('r DRIVER S I GHATWL <br /> *+R� EP CALLER !MT 10"TIFT URLVAR USA AS MG15TRAN <br /> 15. GENEWDR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consigner are fully and accurately described above by the proper shipping name,arid are classified,packaged, <br /> marked and labe{ed/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 /> E)porter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify that t!=te minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(II am a smai quantity generator)is true. <br /> Generator s/OffgCN "Name Signature Qay Year <br /> 16.Internpitional Shipments <br /> ❑import to U.S. ❑E>i:port from U.S. Port of entrylex. <br /> Transporter signature(for exports only): Date-leaving U.S.: <br /> W 17.Transporter Ack nowledgmard of Receipt of Materials r <br /> Transporter 1 PrintisdItYlpecl Name Signature y. qa pay Year <br /> • 't J <br /> Transporter 2 Printed/Typed Name Signature Month Dal/ Year' <br /> 18.Discrepancy <br /> 1 as.Discrepancy Indication Space ❑ Ouen i ty ❑Type ❑Residue ❑Partial Re}d& ❑Full <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> V <br /> LL Facilitys Plane: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3. 4. <br /> 1�� <br /> ity Owner or Operator.Certification of receipt of hazardous materials covered by Ura manifest except as notedin Item 18a <br /> Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />