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Please*tint or type:(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2656-0039, <br /> UNIFORM HAZARDOUS 1 to ID m <br /> T.gage t of 3.Emergency Response Phone 4.Man[ Tracking Number <br /> ba �f b2 <br /> ::.WASTE MANIFEST + 9;r., r :, 911731 <br /> JJKI <br /> 5.Generators Name and Mailing Address 4 11e G erator's SlteAddress(idifferent than mailing address) <br /> Ty y+4 :FiiFi 'f?!Z.i rf;]t7 �� 'fEQd;C"e�rC <br /> 2 f.CA 2 3� <br /> Generator's Phonei&7349-MM <br /> 6.Transporter 1 Company Name• U.S.EPA ID Number <br /> f`•-'tri;�'3 <br /> 7.Tran2 Company Name U.S.EPA ID Number <br /> sporter <br /> e.Designated Fatdfity Name and Site Address ., _ U.S.EPA ID Number <br /> F:-.t:I1-«i?c,�DUR.G <br /> x,150 EAST tal€:0 I9C'D, <br /> r*,"'EL.f-'S,.r . . LaGJ <br /> Fardidyh Phare: <br /> 98. 9b.U.S.DOT Description(including Proper Shipping Name,Harald Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and <br /> ��PackingGroup <br /> (((aany)) tt J ��y rMNO. Type Quantity WtAfd. <br /> �- i'.il!).lbbe�!+JNi(} .. 1 L , 'r,y 1 I ,I�.•.i V.1 I'�.'�'lrf •M.j r �:! <br /> LU mv I. Date <br /> `�'osc �r../if ,Q•6Rh;J ae <br /> tom" <br /> 3. <br /> 4 <br /> 14.Special Handing lnstnrctlors andAdditlonal information <br /> 1~11 11v 1i�C140 <br /> L..-. CWTf ACTOR: FWAO1, R(•VIVZONTAEN A.L _ - <br /> !Sas,7r i r k `311tOU1.0 FrE TRAii"lE0 USr= A70PROI/ErJ tar-F <br /> 15. OENERATOR'S(OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acrxrrately described above by the proper shipping name,and are classified,packaged, <br /> marked and labded'piacanied,and are In all respects In proper condition for transport according to applicable intemational and national governmental regulations.It export shipment ant lam the Primary . <br /> Exporter,I certify that the contents of this consignment conform to the'teans of the attached EPAAcknowledgmentof Consent. <br /> I cer)jty,that,the waste milim¢afion siaiemerd idenfdad in 40 CFR 26227(a)(d I am a large quantlhj generator)or(b)(If I am a small quantity generator)Is Uue, <br /> Generator's Ofle_roes ftiitedFlypd Namp Signature,/ Month Year <br /> 1 ( Vz� to .l 11 <br /> j 16.Intema6aral Shipments � <br /> F— . . ❑Import to U.S.. - ❑Export from U.S. Port of entrylexft:. <br /> Z Transporter signature(for exports only): `"" Dale leaving U.S.: <br /> L= 17.Transporter Acknowledgment of Receipt terials 1 / ~ <br /> i <br /> OTransporter 1 PrMtedrFyped Name % �1 Siigiletuth <br /> CO2r �f <br /> Q Trd%potter2Printacirryps44ame C ature�' f U Month Day Year <br /> ` ! 1 <br /> / t �4 ZL7 16 <br /> 18.Discrepancy } <br /> 18a.Discrepancy Indication Space Ful Re <br /> ' <br /> ❑ Quantity ❑Type ❑Res doe` Partial Rejection ❑ Jedan <br /> Manifest Reference Number: <br /> 181b,Alternate Faci ty(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator). Month Day Year <br /> 19.Hazardous Waste ReportManagement Method Codes(Le,,codes V hazardous waste treatment,disposat,and recycling systems) <br /> LU <br /> 0 1 2 <br /> 20.DesignatedFacitity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as <br /> Printed yped Name Signature Month D Year <br /> in,- V tib �� � lvp <br /> EPA Form 8700-22(Rev:3.05)Previous editions ate obsolete. DESIGNATED FACILITY TO GENERATOR <br />