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Pioase print or ty e, <br /> Form;dtslgnedfDruseonefte(12-pi, writer.) <br /> UNIFORM HAZARDOUS I Generator I0NLjmbq <br /> 2,Page 1 of FOrrrt Approved.OMB No.2050-0039 <br /> S.CiOneMcf'a Name a 37.7--%5?A lcli i Number <br /> � 1 10 <br /> WASTE MANIFEST 1: <br /> Ma .Ad.—I 005,68- 9481 JJK <br /> fiCOn9 GAS r Oenefatflrs"rMAaarm fit(fiffowl than <br /> S I ; � <br /> Gerioranoie,R Phone, (qjcj), CA 95240 <br /> 13-Transporter I Company Nama <br /> A' SIIRVICT,,z u.s,Q—-NUMIDW <br /> 7.TIraMporfor 2 Company Name CA-D 944 Cif)3 .556 <br /> 0777—5 Number <br /> 8.Designated Fa0ty Namo and Sito Address <br /> WXZ' ENF77 <br /> U.S.EPA 11 <br /> RIVER Number <br /> ROAD, WES" SAI-ARA-MIEN"P <br /> Facill s <br /> Phone; <br /> 555 <br /> 9a. Sta U.S.DOT Description(IACIUdhg PrWor Shipping Name,Hazard Class,ID Number, <br /> HM And Packing(3rcUp(if any)) Cwtainm <br /> w 11.Total 12.Unh <br /> w 1No. Type Quantity MI/Vol. 13,Waste Codas <br /> 0 <br /> 2. <br /> LLA <br /> 3. <br /> 4. <br /> 14.Specialru <br /> Flandfinyg <br /> 15. GIENERATOR'SOFFERORIS CERTIFICATION; I hereby dr�lara that the contents of this corsignmont are fully and XCUrati <br /> --ly described Above by the Proper alloping namo,and are classified <br /> 0 Mont <br /> marked and 1,91>01ed/pkir-Irded,and are In till raspects In proper condition for transport According to spn4coble IntOrrEflonol AN nAlJorld pack d, <br /> Exporter,I certify that the contents of lhia const conform to the tarm'-Of ft offsohad EPA ACknOWedgMer,or Consentgoveimmen"raguiltIotris.if export shlp and I am the primery <br /> I cartIfy that N waste Minimization qtotomwt Identified In 40 CFR 262,27(s)(it I am a Iwq.0 quantity 90nerntor)or (IfI am small quqn[Ity ge"rator)Is 1". <br /> 1s;11:tted/Typed Name <br /> Year <br /> 16,Internstonal ShIpmonts I <br /> E I import to U.S. <br /> Transporter signature if—exports—11ADate leaving U.S.:i <br /> Export from U,SL Part Of entry/AXIL' <br /> 17.T?artspwjx Ackn <br /> uMedgment of Receipt of Mawrjnh; <br /> Trarlal)OnOr 1 Rtfndfryped Name <br /> CL MOrrth Day year <br /> I wspWMer 2 nteal I YPGQ Name <br /> Z� 17 <br /> slgn <br /> -Month tray Year <br /> t 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> EJ QuangtyI.JType RmIdue Partial RlIecV, Full R*Cwn <br /> 18b,Alternate Facility(or Generator) <br /> U.S,EPA 10 Number <br /> L) <br /> Fd"Phone: <br /> 16c.Signature of Alternate t-scmny(or rienerafor) <br /> *nth Day year <br /> u 19.Hnmdous w" <br /> ft Report Management Method Codes(i.e.,coda$for hazardoLia waste treatment,ftDoul,and recycling systms <br /> :1 1 2. 3. 4, <br /> I. <br /> 20,D98IgnAtP.d Facifity .1 1 — <br /> Owner or0porator.CmIlIcabon of rf-rtlpt of hazardous materNs covered by the manifest except <br /> PrintedTypod Name Signaturept as rated In item 18a <br /> MO* Day Year <br /> 'A Form 8700-22(Rev.3-05) PrOVIOUs edincins are obsolete. I <br /> GENERATOR'S INITIAL C P <br />