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Please print'or typ67,jFom designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 'UNIFORM HAZARDOUS 1.GeneratorID Number 2.Page 1 of 3:Emergency Response one i 4.Manifest Tracking Number �, WASTE MANIFEST f;; t. 'T l fi ? rt!2 4- i rte+ 0 1 4 0 5 J J K 5.Generators Name and Malting Address Generator's Site Address(if different than mailing address) . .BOX'd Sk" :r:: �t S. �YF Cir~~Lr a,:Y Generator's Phone: 209 46"421 6.Transporter t Company Name, - U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number y 8.Designated Facility Name and-Site Address U.S.EPA ID Number j _ f��Yftf�t�`C��'�?�•{��s�,ta€ai�s�.��: LO F s1 SOUPH R0YLE AVENUE Facility's Phone: i 5L:-;; �s;f"� C A D u 9 7 0Er p mss' go. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10':Contatnerss ';"-: 11.Total 12.Unit 13.Waste Codes HM and Packing Group(If any)) No. Type Quantity Wt.Nol. p 1 N01"OU H,*ti c:JRIDI US V"-AOFE,S0IM-e(0112(SOiutDS1 'y '� D Int �� a •�_ Lu z. r LU st; 3. i • , t I I 4. 14.Special•Handhng Instructions and Additional Information %" Z-' ^ E €E rlf ul_GI�EMT*--' - cod--ta.�iti�"Gd : 1 �� ca"? 5l 3 : �s F L4 �'E S. fig= e4at AOR6 IAT9 KRSONAL FROTE01VE I `'u;€ �; 16, GENERATPR:S(OFFERORS-CERTHCATION:I hereby declare that the contents of tnis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked land labeledlplacarded,and are IA all respects!n proper conci tion.for transpojlfc=- dfr�fo.applicable international and nations governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignmect conform mPaAcknowledgment o`Consent I certify that the waste minimization statementidentified in 40 CFR 26227(a)(if I am a large quant ty or)or(b)(if I am a small quantity generator)Is true, G npAg slOfferots Printed(T Name f = ° ! ' Si atur Month Day Year -+ 16.In�maB 8hlpmehts U „ i— ❑Import to L'S. Export horn U.S. Port of entry/exit z Transporter signature(for exports only): Date leaving U.S.: w 17.TranspcirterAcknewletlgmentofReceip(ofMateria's Transco Ker t PrintedfTyped�me- / f Signatura Month Day Year c°n L/ �` ✓F`�^ /i`',`G^'fi +�i: `�_' ;– c— MFS !� Transporter PrintedrTyped Name mature, Month Day: Year 18•Discrepancy 18a.Discrepancy Indication Space El quantity 0 Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 1 Bb.Alternate Facility(or Generator) U.S.EPA 10 Number rai Facilitys Phone: W 18c.Signature ofAltemate Facility(or Generator) Month Day Year Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)LU 20.t7e4ated Faclily Owner or Operator.Certification of receipt of hazardoup•mafepals covered by the manifest except as noted in Item 18a j Pdntedlfyped Name /} �i � Signature � { � -• Month Day Year,,. -V � / 12 EPA Form 8700-22(Rev..3-05) Previous editions,are obsolete, DESIGNATED FACILI TO GENERATOR STATE(IF REQUIRED)