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Pleas pint or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST i;41 1_0 0 0 :? 9 is ai. . � �t;�}{D? �.`'.+�-°i-:'!� t � �I ' � � i'� � JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> VAN Of.POL RITERPRISE5..S FOCKTON <br /> stT:~?; Tr r r 7 ..�, e;L"J, <br /> Generator's Phone: �•e4`�'•=�•�-= TxG;I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> X-1,URY EENMONNI I,AL SERVIC LS a, <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 /> `;IEhill tN 5 tN DU-13TRY.IN C. <br /> 1-)'3 01011TH }?Q`1lE_AVENUE <br /> i.W3 ANGE.LE:S CA 9()05 P <br /> Facility's Phone: (32'V7 7-1 Fl("-0 <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 any)) No. Type Quantity Wt.Nol. <br /> 1. Nf:sN.{,/_RfoH;I►ARI[Ku ll%I` -',!T..SO!,1D Rr:A!r i1 <br /> 1-7 oo <br /> ZLU <br /> 2. _ <br /> 3. <br /> EB 17 2016 <br /> 4 ENVIRONMEN <br /> L <br /> I= !TH nPP.ART!lAGn1T <br /> 14.Special Handling Instructions and Additional Information <br /> rVs1:4+iwE4�f1::Y <br /> 11-01-01 JACi :CHktVIIkEC-. -800.424-9300 1V€lER60 1 : A. I i'r'OF.i..z.#r+(-1. ,RP I!.,4r,.7,.;rrf II';i! <br /> 11"(W A.1.1016747.0 PERSONAL PROTFI::TI!'E EQUIPMENT <br /> r <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 gerrarator)or(b)(if I am a small quantity generator)is true. <br /> Gator's/Offeror's Printedd//T Ped Name Si at e , Month Day Year <br /> -J 16 International Shipments1 <br /> i- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> l'- Trans iter 1 PrintedlTyped Name Signature / �7 Month Day Year <br /> ZTransporter 2 PrintedfTyped 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 /> V <br /> Li- Facility's Phone. <br /> Lo 18c.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. i .�` �1 2. 3. 4. <br /> 20.Designated Facility Owner o Operator:Certification of receipt;Jf hazardous atedals covered by the manifest except as noted in Item 18a <br /> Printedffyped Name %/ ( / Signature Month Day Year <br /> 1 `Y <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. �� I � V'b 4ESIINA T_7 FAG ILIT y TO QEi-1E <br /> CIA V.�'-� <br />