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(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> AZARDOUS 1.Generato,ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> MANIFEST C A 1 10 0 u ! tib 4 1 3 y rs#,11. y,;Uk) � 12 21803 JJ K <br /> cors Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 0 box 1.107 4ts,3Y►y AtIRVOfl: WAY MONTHLY WO C*Lf <br /> N 209 4 3 7 1.(„A 55205 STOCKTON CA :#5205 <br /> denerator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des ign@tt@ed�F�a�i�r"rq�ty�tp��arr��e and Site Ad ragss U.S.EPA ID Number <br /> t►S a, t�1H11_Yt 1.0-��hJ_'.1ts:La .�1. <br /> 5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA W0058 r;,� 1)0 9 7 0 3 0 9 9 31 <br /> Facili 's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number. 10.Conta ners 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Ccdes <br /> No. Type Quantity Wt./Vol. <br /> 1 <br /> O <br /> w <br /> C 2 � <br /> 3. FEB 17 2016 <br /> E:KIjj1RQh1hAE TAI <br /> 4. <br /> Ii.. AITP nFD�!!?T�A�NT <br /> 14.Special Handling Instructions and Additional Information <br /> .EKtRE(, t-800-424-5300 NAE981 171.9£17 t 7 1 1 PROFN.E N')f!s 0V,r1.a <br /> UIL I WLK)b,tW. Ael t5/!34 UIV 54KIUS"flON Al 1019261b 0 All"iNK 1NATE PER90%AL PPOTECTIVE <br /> 15. GENERATOR'S/OFFEROR'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 generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeror's Printed(Fyped Name Signature Month Day Year <br /> 16.International Shipments <br /> E- ❑Import to U.S. ❑Export from U.S. Port of entry-exit: <br /> Z <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> U 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> Cn <br /> Q Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantic Type Y ❑ yp ❑Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ra Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/typed Name Signature Month Day Year <br /> sti <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />