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ro <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 //� Q 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CA C.00,L61(4 T C� 018474656 JJ K <br /> 5.General rs Name and Mailing Add i Generator's Site Address(d different than mailing address) <br /> 16013 RAO( briq-t Maw) t a1,u��,� 1 �P 1�'I�� S�;�h ar�gian 1 Lq�•�'o <br /> Generators Phone: 5— l,f `l —I wo ) <br /> 6.Trans over 1 Company Nama U.S.EPA ID Number <br /> \j ben CNDC)S316G-ro-+ � <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 /> Oros �' C)Vty oV\ I+nC' C1�b oZ8 coq a�9 <br /> i Vit® t��es-t� i��-h Slot.-e� 1��(3�ac�,� ��•°laat3- - <br /> Facility.Phone: <br /> ga_ 96.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number," 10.Containers 11.Total • •12.Unit <br /> and Packing Grou if an No. Type Qua yyt,fyci, 13.Waste Codas <br /> HM 9 P( Y)) YP rr6ty .. <br /> o of tZ�tz; c�.avd �.su�c's q-� 35z <br /> ~ (,avc��nni�nt�Ica "LdltfoCO.'r od1, 1� <br /> Uj00 Z2 <br /> Uj <br /> LLJ2. ^ '4 Iq9� J�1 P'Se). eve "P� 11 r DYYi 2Z3 <br /> �. 5'lJ s <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> �}a it r <br /> Z�vov' 1I-e-o 10o53q <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of ttds 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 ide Gfi 0 Ct2 262.271a)(111 am a large quantity generator)or(b)(ill am a small quantity generator)is true. <br /> GeneratoeslOffemes Printedrryped Name =" SI9-n M��� _ �_ Month Day Year <br /> 16.International Shipments <br /> � ❑Import bUS. �E>grorttianUS. Port ofenbylexd: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Ix TT port l Pdntedfr ed Name _ Signature ., ITh Month Day �Year <br /> 0. r v 5-•--%Cl <br /> QTransporter 2 ' ted(Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue, ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> uQ. Facility's Phone: Month Da Year <br /> W 18c.Signature of Altemate Facility(or Generator) Y <br /> Q , <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. aa r <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials vered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature MonthDay Year <br /> Z. (8{ <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12899.0671 <br />