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11/12/2007 09:03 FAX 2093033231 GEORGE IiISHIDA INC 11007 <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 Io Number 2.Page 1 of 1 3.Emergency Response Phone Manifest Tracking Number <br /> WASTE MANIFEST :;r4i.110111;1't'f<t t 1t.,_ .d(;,. i id; S. 003i—l "5673 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> UC-Qr4C;E WSIADA,'rK,rl I�,r X135+ <br /> 17:25 lat'ERPAAH <br /> Generator's Phone: <br /> 6.Tansporter 1 Company Neme U,S.EPA ID Number <br /> 5, 0P HA.,'d,FIGS�7C�L1�T 0W. <br /> 7.Transportar 2 Company Name U.S.EPA ID Number <br /> 8,De31g� t d Fac li ifY,Neme anctSitp A4dre8% U.S.EPA ID Number <br /> l�lL.'.�a•'�!f>♦9�.1'1C.)�-4Jh�frJ'j11 r ter;- X11"1 IJtil�f�'`'" <br /> 1 1055R,ANCYip>�"TE P.Of-H%ri1.1 <br /> C'0RfjKTVA,CA 9"11742 <br /> Facilit's Phone; <br /> ga 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if ary)) No. Type Quantity Wt./Vol. <br /> {��rtd•k;=I?.A FV �RDQI� S't?4°AS I i;;;;01-i 0. FAVI i>? P 2, ) 2 <br /> p GRE! I+ <br /> �a <br /> w <br /> Z 2. <br /> W <br /> 3. <br /> 1 <br /> 4. <br /> 14,Spoclal Handling Inatructlona and Add1 Anal Information <br /> P¢?OP-I LE-'AtP <br /> MI-)ROPIRIAr:WOTECTI `Lt:il'ltiti <br /> SEE 1:-90#1';•t <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereoy declare that the Contents of this consignment are rvlly and accurately dourlbed above by the proper shipping name,and are classified,packaged, <br /> marked enc iabeladiplacarded,and are In all respects in proper condition for transport according to applicable Intenatlonal end national governmelrai regulations.If exporl shipment and I am the Primary <br /> Exporter,I cartlfy,that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified 4n 40 CFR 262.27(a)(if I am a largo quantity generator)or(b)(if I am a smell quantity generator)Is true. <br /> Generataealofferors PnntadrTyped Name Sfgnatura Month Day Year <br /> .-1 16,Internatianai Shipments <br /> F ❑Import to U.S. Ll Export from U.S. Part of entrylexr, <br /> Transporter signature(far exports only): Data leaving U.S.: <br /> Q� 17,TrarsportarAckrowledgment of Receipt of Materiels <br /> g Moi Day Year <br /> Tranaporta�yPrnted/lyped home �, .rte . y signature `M r ^ T <br /> Signature Month Day Year <br /> ransponer 2 Pdnted(ryped Name 9 <br /> 18.Discrepancy <br /> 16s.Discrepancy Incication Space ❑ Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> Manifest Referencu Number: <br /> 1 Bb.Aitemate Facility(or Generator) J.S.EPA ID Number <br /> v <br /> rai Facllity's Phone: <br /> 0 1Bc.S'gnatura oFAltemate Feali y(ar Generator) ror <br /> tn Day YON <br /> a <br /> 19.Hazardous Waste Report Maragemerl Methoo Codes(Le..codes for hazardous waste tma(merd,disposal.and recycling Systems) <br /> 0 1 2 3, Notice_New federal form. State of <br /> California requires generator to photocopy <br /> and trail to DT'SC within 30 days: <br /> 20.Designated FsciPty Owner or Operator.Certification of receipt of hazardous materials covered by the menlfest except as noted in Itom 18a P O Box 400, Sacramento,CA 95312-0400 <br /> Printedl yped Namo Signature <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />