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r <br /> F. <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-01339. <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of FT Emergency Response Phone4.B07489481 <br /> nifest Tracking Number <br /> WASTE MANIFEST CAL J001 :136 1=6x3 � �tyg,f%� . d<a: JJK <br /> 5.Generator's Name and Mailing Address Generators Ste Address(f deferent than magizg address) <br /> t;t`s . �r .f�3:�tw iaf F.vs13 . i 95241...i <br /> Gene.alora Phare: %, �.si 12 -5/ 6 <br /> S.Transporter 1 Company Name U.S.EPA ID Number <br /> Ci �.!. s11t>1` a4iiy°3r .? .1 Yita:7E,:Ai1 .3-r J34 CtiJ:i .}tin e'J.^ <br /> Crt <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 11)Number <br /> yy..XS,�gqa+�• 'i <br /> `, �i++ <br /> 80-U s i <br /> FactMys Phone: ?) :5 i�i---`-747 A" 044 CO3 556 <br /> ga, 91b.U.S.DOT Description(itckuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pecking Group lid any)) 13.Waste Codes <br /> ... „. _ _... _.. No. Type Quantity WtNoi. <br /> 1. i•:,.,r-;�. ,:,:: .,:::. F,.,..ti,�.; ,_day;.; , �,ir..<. .S <br /> Z 2. <br /> LAJ <br /> 3. <br /> 4. <br /> 14.Special Hancgirrg Instructions end Additional Irdormefion t� <br /> JAW�I�y f TO <br /> TRAINED <br /> it krZ J <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consE nment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am Bre Primary . <br /> Exporter,I cerfify that the contents of this consignment conform to the terns of the attacired EPAAcknowledgment of Consent. <br /> I cerfily that the waste minimization statement identified In 40 CFR 262.27(x)(81 am a large quantity generator)or(b)(WI am a small quantity generator)is true. <br /> GewaWs*fferors Phnted Typed Name Signature Month Day Year <br /> 18.International Shipments <br /> ❑import to U.S. ❑Export from U.S. Port of entry/exit <br /> z Transporter signature{far exports only): Data leavlrrg U.S.: <br /> Lw 17.TrarsporterAcknaMedgment of Receipt of Materials <br /> Ij Transporter 1 frintedlTyped Name, Signature Month Day Year <br /> CL <br /> za TraWuporter2 Printed/lyped Name Signature Month Day Year <br /> OC <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quant <br /> ty ❑Type 1:1 Residue ❑PaWBeI ReJeclton ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Atemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> rQ+- Facillty's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> ac <br /> z <br /> N19,Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UA C3 1. 2. 7- <br /> . 4. <br /> 20.Desgnaled Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as rx:led in Mem 18a <br /> PrintedlTyped Name 'gnature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />