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„tease print or type. (Form designed for use on elite (12 -pitch) typewriter.) 14431 571 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2 Face 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFESTCAL-i;GC0�3�35,3 tis` y' 57-256;17000039957 DAT 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) S.tE ; SM JOR001A. PIRPAV 4 K.t �MFU / f € 5si t i PORT BAY Generator's Phone: SiC01iEa Cit 9Sau, i2ffU,466-4729 5e9CUM CP 95266 (209AH-47H 6. Transporter 1 Company Name U,S, EPA ID Number kis r Env3.t"Ot't1:1e9'.t:al Management of Cal- form -a' € Y CAR0002106L! 7, Transporter 2 Comparry Name U.S. EPA ID Number 8. Designated Facility Name and Site Address r U.7�..i2iir�PY� �p�s�5rt''S}EgisAl(iS./�r.f4rl��t�,. NOT, L.1_L PDA GJir d.35B 2R4Y(RER2?;!_ SERVICE -13 - =�•8 , ;it{ IS�J� Y��4C R,:lltn ��Y Facility's Phone: 14MIG MEOW, CM 9542 (9f3F 351-H99 'P AD19 ,* ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Container, 11. Total 12. Unit 13, Waste Codes No Type HM and Packing Group (if any)) Ouami WtNoL 1- 111I R?2: K 61NICTF DEW TIRP T -H, IATEHAL 3 PUT1 F4 EA �r u 1 1 1 2. IJN170 WADI_ FA34T RE)_PIt;V APTIERTAL b '3I )011` 8 11-674�. �3 LU x 3 CF - i 3. U442901 VA!'7F PE T-1`11 ES., f-:I(UIR, TOXIC, FLim- MILE N.D.S. .. I x. €%ItZTgOR'. PET Rii(EU sfIaTilii!le i 6.1 t31 f'C`II 4ER04) 4. ii?;79w{ SfE PE."^'.Ims_S, l aun' T-4upj FLAW.YE., fi.O.3. jti0f. t-�t fIlRINIO1N, PETUIELPR KSTiIJ-?TES) 6.1 13i PE 1 RO(WI) - or, -_.. 14. Special Handling Instructions and Additional Information is F�v ! 9321'b-�� CFiF(I 7 F (2@ S32f45-$9 ERE(IZE) LOOSEPRCK OCLi��) LWSPICY, {_ ll -93 Rr _UPM- OESiIVUE-3r (4) 532M-10 - ERG(1311 LRIMCK- PE TIUDE—Sq, 15. GENERATOR'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, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable intemationaland national govemmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if i am a large quantity gener or (b) (if I am a small quantity generator) is true. �VeneratoesfOfferoes PrintedlTyped Name ®a I G DDaayy,, ar v6� ✓ `-kf _r Z 16. International Shipmentsf Import to U.S LJ Export from O.S.Port of enbyle>ut Transporter signature (for exports only): Date leaving U.S.: UW 17. Transporter Acknowledgment of Receipt of Materials �j Transpo er 1 Printedffyp are Sic al e Month Day Year VHF,,,, �� 3 17011Z Q Transporter 2 Printed/Typed Name Signawre Month Day Year 18. Discrepancy IBe. Discrepancy indication Space ❑ quantity []Type ❑ Residue ❑ Partial Rejection L_l Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year d z 19. Hazardous Report Management Method Codes (La., codes for hazardous waste treatment, disposal, and recycling systems) UJ `Waste 1. !/ 2��/ 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed yped Name � r Signature Month Day Year s �s ern o - EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)