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P <br />r <br />ease print or type. (Form designed for use on elite (12-pitcn) ty <br />UNIFORM HAZARDOUS 1. Generator ID Number. <br />WASTE MANIFEST I 1 ,i,. <br />5. Generator's Name and Mailing Address <br />1100 HQtAth It t Dot ado Avw . #9 <br />Ktocktton, (:,a . 9!)205 <br />GEN Ri"Icha co rdovrii, LxA:.: <br />1.1OS5 Whito Rt)vk Road <br />Reliku-'40 Curdov&, CA 9S742 <br />Facility's Phone: <br />9a. I 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />2. Page 1 of 13. Emergency Response Phone <br />0 "on ll;gxat Iia�xa,:xi�vtt2u twaariat !;a►llt! �pr<oas�yrt <br />a t3a�a�an+e) <br />LU <br />M 2. <br />Mart 6tc;*4.. Hxrwr.4ouvm wasrt9r ?Szsi st--ii i�9f <br />Form Approved, OMB No. 2050-0039 <br />ng Number <br />)20672 FLE <br />t" AR00067OU0 <br />ID <br />10, Containers 11. Total 12. Unit <br />No. Type Quantity Wt.Nol. 13. Waste Codes <br />X} if7,Sy2.�; i"A(3-• �>•-•i�1B�,�A1""Cliff-�-... <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 orb if I am a small quantity <br />enerator's/ eror's nnted/Typed Name ) O ( q ty generator) is We. <br />gna ure on ay <br />16mtemalici at bhipmentS <br />❑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 />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue <br />18b. Alternate Facility (or Generator) _ Manifest Reference Nur <br />J <br />U <br />Q <br />u- Facilit 's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) <br />Z <br />U) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ 1 2• 3. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pnnted/Typed Name Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />❑ Partial Rejection <br />U.S. EPA ID Number <br />I <br />�4 <br />❑ Full Rejection <br />GENERATOR'S INITIAL COPY <br />