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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number <br /> WASTE MANIFEST t A t 0 0 0 3 7 :lNOW , ' 0 c;+ � (,=z )n7 ) ' . # S 8 7 0 ��� � JJ <br /> S. Generator's Name and Mailing Address Generato(s Site Address (if different than mailing address) <br /> MOIN, IN AUT01`004IVF. PrTIA `( RAGS v <br /> 4171 Ifdi')WITPIAIL WAY <br /> TI ?Oi'Y <br /> Generator's Phone: 201) A3('3- 4C'I0 1 <br /> 6. Transporter 1 Company. Name U.S, EPA ID Number <br /> WORLD Oft, ENVIP NP IENTAI. �' IFr(VICF4 ,=; <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> 63 16 SO H B YI,F, r4,UEII# IF <br /> L08 ANGELFS CA 9005 i" <br /> Facility's Phone: ('`23)o?t" 7-1. - 0 <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HMand Packing Group (if any)) . No. Type Quantity Wt.Noi. 13. Waste Codes <br /> 0 1 ' 4`40NI DCPA HA,21R00 (V)'WA8 SOUD ( C) II .'i S(at _ ID PAPER Cfl.if; H.`7 ) <br /> f <br /> E net f'' <br /> Z 2. <br /> LU <br /> 3 " <br /> 4. <br /> 14. Special Handling inshucliomi andlMdlfionai Infdrmation <br /> I `�} Y 3 � ' . 1It I ' #C+•�t �7f !) t3t) WOES fFFfi iiNNAE . Ol'i f' I'dil=fLl ;? 5rai i)"S I.CS,") 1 1 ci:t t3ll .`r` <br /> F1hF'I t)i'RI�t, 'E" PP I { f iiPdiJil;'CII <br /> 15. GENERATORS11 1 1OFFEROR-11 11 S CERTIFICATION; (hareby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeled)piacarded and areln'all iespects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> Ezpoder 1 oettitythatthe contents of this consignment wnform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify tRat the Waste rplgr lzation ataleipent idgntffied in 40 GFR 262,27(a) (if i am a large quantity generator) or (b) (if I am a small quantity generator) Is true. <br /> Generat6(sfOTfer6e P4nt6g)iper) Name : : Signature Month Day YearIfl <br /> _ <br /> s f <br /> — r 16, International Shipments . <br /> , ! F] Import to U.S. ElExport from U.S. Port of entrylexit: <br /> Transporter signature {(or agli6as only): Data leaving U.S.: <br /> W 17. TransporterAcknovdedgment of Receipt of Materials <br /> Transporter IPrintedfTypedName. Signature Month Day Year <br /> O <br /> CL <br /> Transporier2 PrintedfTyped Nairne ( Signature Month Day Year <br /> h- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space EJ Quantity ❑ Type ❑ Residue <br /> E] Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number, <br /> 18b, Alfemate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> ILL <br /> v <br /> FacilitysPhone: <br /> �W 18c,Signature of Alternate Facility (or Generator) Month Day Year <br /> d <br /> CD <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (i,a., codes for hazardous waste treatment, disposal, and recycling systems) <br /> UJ 1 2, 3, 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> Pnnte !Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. <br /> GENERATOR 'S INITIAL GARY <br />