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Please print or type. (Form designed for use on'elite (12-piaaecl <br />Fnm, AnnrnvM nUR w. 9nnn.nn'1e <br />EPA Form 8700-22 (R v. 3-05) Yrevious'eamons arra onsoletej <br />i' <br />DE$1GNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />14. Manifest Tracking Number <br />WASTE MANIFEST - c - .- _ _ <br />P" - ' 1-5,4 <br />(j 3 $ 1 9 7 JJK <br />5. Generators Name and Mailing Address Generators Site Address (if diRerent man mailing address) <br />'JLTRAMlAR BEACON STAT+(_.•.! A <br />555WTHIRD STREE7 4701Jh!AtN TRE <br />1AP.IFC:RD CA 93230 fIANTEC» CA Q54 - <br />Genealors Phone: 5 ': G <br />6. Transporter 1 Company Name <br />Foolopy C ortrol I ntlstri rs U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number` <br />8.gnpted Fa gldy Name and She Address U.S. EPA ID Number <br />G910;jy' 4oP.Vol lTndusgTi_5 <br />255 Farr EDouie'vard <br />Old'in»nd CA. 9430i <br />Facility's Phone: W U s 0 - i :jW e - -U <br />L <br />gra <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />18. Containers <br />11. Total <br />12 UMt <br />HM <br />and Padding Group ('d any)) <br />Ouansty <br />WLNd. <br />13. Waste Codes <br />No. <br />Type <br />1 bion-RCRA Haza.aous';daspe. solid <br />Fo <br />w <br />fEMP7V STORAGE TAf'gX:tSi <br />z <br />2. <br />CDw <br />3. <br />4. <br />14.S it Handlii q Instructions and Additional Information <br />...11P'PY 'TCYRAGE ':'A -1K- TANP: #_ _ <br />ECS 30E # 52'1'3251 <br />LIE?R PROPER -PTE C.HF14 IiiiF7 fG. wrEIGHT3 A:iO '.rOLCME3 hF;E hPPk_" <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,jard am classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for Transport according to applicable intemational and nationalovernmental <br />g regulations. If export shipment and I am the Primary <br />Exporter. I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent ' <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (N I am a large quanfity generator) or (b) (HI am a small quantity generator) is true. <br />Generatorslo8eno s Pdntedrryped Name Signature N Month Day Year <br />�Ott�.\11 �� S-v� - _J -� �.-� "r� r✓ Udo (� <br />J16. <br />r <br />International Shipments <br />❑ Import to U.S. ❑ Expod from U.S. Port <br />= <br />oteneylexit <br />Transporter signature (for exports only): Data leaving U.S.: _ <br />W <br />17. Transporter Acknow! cIgmem of Receipt of Materials <br />N <br />C <br />T rt Printed/Typed E S' g Monty Da Year <br />Z <br />Q <br />Transporter 2 Printed/Typed Name Signature F Month Day Year <br />C <br />F <br />Discrepancy <br />t18. <br />18s. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ FW Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (w Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />Maj <br />18c. Sgnature of Alternate Facility (or Generator) Month Day Year <br />Q <br />z <br />h19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. <br />2. 3. <br />4. <br />20. Designated Facility Omer Operator Certification of receipt oftrezaeus materials covered by the manifest except as rMed in Item 1 B <br />1 <br />Pdnte(v typed Name r Signature Nbmh Day yam, <br />_ <br />10 t <br />EPA Form 8700-22 (R v. 3-05) Yrevious'eamons arra onsoletej <br />i' <br />DE$1GNATED FACILITY TO GENERATOR <br />