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Please print or type,.{Firm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> -'Uft1'(3RM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> C�1 <br /> WASTE MANIFEST CM771WO � 14W?8&7= p 785059 FLE <br /> 5.Generators Name and MailingAddress <br /> �1�9 Ta*UFM ( ererA n„ i , ddress) <br /> 05 S.El Doodo Avenue SIB <br /> R1 <br /> '0�1���.f�l11 s. �. <br /> CA 906 <br /> Generator's Phone:2094661M 2n14 <br /> 6,Tr nspoRerl om any U.S.EPA ID Number <br /> t cd Ttia1104 t 6C. (SV) CARDOOiD7Y1 M <br /> 1_1ransporter 2 Company Na t U. _ � <br /> 1'"l dC c '(' �C S -4 R(7NiVf t� , q I ct d'd7 q <br /> � � L <br /> 8.Desgnat� li Name and Site Address U.S.EPA ID Number <br /> 8133 Edth Bled NE mod NMD0022DO627 <br /> A�plusi>�a161NMUIM <br /> Faciitys Phone: 55 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Contalners 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> 1 W www t p 363 <br /> � �/y <br /> W <br /> 2. <br /> RECEIVED <br /> 3. MAy.2 11 Z014 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> p f*ct Dccu W 6: 143 <br /> 1�E 11W ACi�MCAA- � ��� > <br /> 15. GENERATOR'S10FFEROR'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 labelediplatarded,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 I am a small quantity generator)is true. <br /> Generetor erors not ypad Name Signature Day Year <br /> j 16.International Shipments <br /> t` ❑Import to U.S. ❑Export from U.S. Part of entryle* <br /> z <br /> Transporter signature for exports on : Date leaving U.S. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporteredfryped me <nature ay Year <br /> a <br /> Z Transporter 2PdntedfrypedName �t Signature th Day <br /> yj A <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space .--� Quantity Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S EPA ID Number <br /> J <br /> v <br /> Facililys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> t- <br /> ¢ <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. 2. 3. 4. <br /> ,�/1 <br /> a 20.Designated Facility Owner or Operator:CeNfication of receipt of hazardous materials covered by the manifest except as noted In It 18a y <br /> Printedfi N e Signature month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. �` DESIGNATED FACILITY TO GENERATOR <br />