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-Pleas3 print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-00394. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number JJ K <br /> WASTE MANIFEST t:d►: fY�}t is< A. ry j f1ZE�f{ ` '3;?.l01.14 <br /> 0-5 5:,Rr <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> VAN Of:"POO I.IT[:� PRISE S-•S F�hi KTON � > - �, 7 ;K�t�: �;r C)tA a BLY '10"Y{D s�rm'_'�' <br /> •�Tt K�r CS e t-- <br /> Generators Phone: 2 "f '" " <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASE«"URY E:NVIRONMaEt��FAt SEf4Yt�;.ES. i1 i r+ h't' ;r�r <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 /> S;lEPAERS tNOUS1RY.INC <br /> ij�-�75 SOUTH ROYLE AVENUE <br /> LOS ANGIFLES CA 90058 J� •Cr <br /> Facility's Phone: <br /> (32'0577T-1500 <br /> 500 <br /> 9a 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. <br /> O �l?{b.!i.�,?Cf�rri4 i.1;1� �^y �y�� `� {•; , <br /> p '( <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> O <br /> 4. <br /> 14.Special Handling Instructions as <br /> E IN1��1 I..P ika E N�.--1 C-0 3.�.- -l•� i' "t. ,i"?{..\.'l�'TQC-`..". 'i '^f..i,3��'i�.:.}�.�t't�� fel?., . <br /> 15. GENERATOR'S/OFFEROR': ind accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarde mational 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity ge rator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offeror's f n'nted/T ped Name Si aty ; Month_ Day Year <br /> -1 116.International ShipmentsJ ry J <br /> ❑Importto U.S. ❑Export from U.S. Port oT ent lexit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Si nature / ' Month Day Year <br /> W- Trans orter 1 PrintedtT ed Name 9 /`l� f <br /> Z Transporter 2 Printed7Typed Name Signature Month Day Year <br /> W <br /> I- <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 /> U <br /> LL- Facility's Phone: Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> m19.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.Design-at'd Facility Owner o Operator:Certification of receiptof hazarOous aterials covered by the manifest except as noted in Ilam 18a Month Day Year <br /> Printed(Typed Name 1%/ / Signature / <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. (� \.V ��(,b DESIGNATED FACILITY TACT, �Ef 1C'63�a <br /> CY-(\ %V1- <br /> N - <br />