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Plm�-Zinf nr tern !Farm deeinned far use an elite 112-flitchIiteLl <br />• <br />Form Approved. OMB No, 2050.0079 <br />EPA fam 8700-22 (Rev. 7.05) Previous editions are obsolete. / DESIGNATED FACILITY TO DESTINATION STAKE (IF KLQUIKtu) <br />UNIFORM HAZARDOUS' 1. Generales ID Number <br />WASTE MANIFEST :4t y -7 <br />2 Page 1 of <br />r <br />3. Emergency Response Phone <br />PzZz <br />4. Manifest Tracking Number <br />003930600 FLE <br />S. Generatm s Name 'ridMailingg Address 1 Generator's Site Address (if diSerenl than mating address) <br />;`�n47' � ve v, wn.s4Z �«-..:ccs 1 aC <br />IUS, <br />133;3 r'_ 7 w,e v r e 4d <br />y <br />Lod:, [A 4 y_Q <br />Generators Phane: it <br />6. rAanspoder anpany ame EPA ID Number <br />/I <br />A� mK[ad ehe�:cu�ivoo0 70SS U <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />e. Designated Facility Name and Site Address U.S. EPA ID Number <br />fr ILT 10.2 R1F7 yee 1^16 SE,[./1 -rlU <br />(opf A&vTr Avee <br />P, Aa.T0. CA <br />`/�Jf- <br />Facility's Phone: L. -.Q TJ <br />9a <br />9b. U.S. DOT Description (Including Proper Slapping Name, Hazard Class, 10 Number. <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packktg Grap(If any)) <br />Quantity <br />W1.1vol, <br />' IUoA1 !�c/�A >apz +Rh es rn,A re, LruU, ✓� <br />^II^^ <br />w <br />2. <br />3. <br />' <br />4. <br />I <br />14,�Special Handling Instruclions and Additional Information <br />'ld010222`7 Ci=i-asr 6K , <br />L4 <br />Lo <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declam that the torpents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelecifplacarded, and are In all respects in proper mnA6on for transfead according to applicable International and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of ms consignment conform to The terms of the attached EPAAcknowledgmenl of Consent. <br />I certify that the waste minlnuzalicn slatement identified in 40 CFR 262.27(a) (if I am a large quantity general(b) lit I a a small quantity generator) is hue. <br />Gen or 0 e s male <br />Name alone <br />on ay Year <br />/14S r <br />Y 7 0` 10 <br />F <br />i6.International Shipments ❑ImpM Io U.S. ❑Export hanu.s. Pod ofentrylexit: <br />= <br />Transporter si nalure for exports ora Date leavi U.S.: <br />W <br />V. Transporter Acknawledgmant ece' of MaterialsTrans <br />a P mitiRyped Na gnat nth ay ear <br />o <br />a <br />/rtefZ IO Iv <br />Z <br />TrmaporW2 PrintedRyped Name n re Month ay Year <br />18.Discrepancy <br />I <br />1Sa. Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑ Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b, Alternate Facility (a Generator) U.S.EPAIDNumber <br />J <br />U <br />LL <br />Facilil s Phone: <br />CW3 <br />181 Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />2 <br />y19. <br />Hazardous Waste Report Management McBrod Codes (Ia., codes far hazardous waste treatment, disposal, and recycling systems) <br />2. 3. <br />4. <br />20. Designated Facility Owner or Oper. tar. Cerbfication of receipt of hazardous materials covered by The mandol except as noted in Item the <br />1 <br />PrmledRyped Name Signature n Day Year <br />4 ts, , �9;7 S a <br />EPA fam 8700-22 (Rev. 7.05) Previous editions are obsolete. / DESIGNATED FACILITY TO DESTINATION STAKE (IF KLQUIKtu) <br />