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�L D <br /> 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 rm009776925 <br /> afest Tracking Number <br /> WASTE MANIFEST GAS 11111 10X+ tr-'414 ,:.., JJ K <br /> 5.Generators Name and Mailing Address aGenerator's Site Address(if different than mailing address) <br /> wt joaq.An i,_Xi. ky t.nvfrotwrtental health L)epl, tack l arxr Rd S of Ccxn4took i2N <br /> iff(itl E25tlia?eRoti live+t�aG hnr41 Xt ('R, o431a <br /> Generators Phone: 209-'6S"3439.13 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1 Z-5ermce'"Pomona-LP <br /> 8 Desjpnated F�aa Name and Site Address U.S.EPA ID Number <br /> tC.1V''vF'S LLQ. .;:•�t;„�o•. <br /> 415 15t's Avemn <br /> frtglewood,CA 9W01 <br /> Facility's Phone: `;1'�'' KA33 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 1 UN1263,Waste Paint Retatod Mall"al,3,PG It.RQ(U001) DF1 W !• 331 0001 <br /> o _ <br /> a <br /> w <br /> z 2. Nor►-IRVtA Hanardove Waste 5ohd,(Dabrls,PPE) (IF 150 P 352 <br /> w <br /> 3. <br /> 4. / <br /> f <br /> 14.Special Handling Instructions <br /> (lddltbnal Information <br /> EI(Gft M ordwr 121 'RO Book In Cab- Wear apptvpnate persorial protective equipment when handling <br /> 1(1x55) 2(2K f <br /> JottM 51!L ERERN 201 b-01-1)5 <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby 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/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI a a small 94antity generator)is true. <br /> GenerSfdr's/Otf ror's Printed(fy ed Name, Signatur Month Day Year <br /> t <br /> J 16.International Shipments <br /> F-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LQ: 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature ? Month Day Y� <br /> O <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ❑ ❑ ❑Full Rejection <br /> ❑ Quantity Type Residue Partial Rejection j <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> w18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 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 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />