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Please print or type.(Form designed for use on elite(12-pitch) y,.writer.) 00,6 7-00 SC'PPW b/I .014 <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> G 6 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> StOCKtOn US0 StRA9 Hill0b'A*01)i <br /> 1.944 W 0 Plinal Drive AtDi:but 41 arc',smidt :LG2i Brookside Road <br /> 5ttl4fan,r,-,A 595,11055 11 , , I " <br /> 91f5,r*tQn,CA9520? <,6 <br /> Generator's Phone: C C f i -- <br /> 6.Transporter 1 Company NameU.S.EPA ID Number <br /> (I <br /> wjif iu) <br /> irt LA <br /> 7.Transporter 2 Company Name U.S.EPA IDN1 <br /> AN 11 2016 J <br /> 8.Designated Facility Name and Site Address U.S.EPA IDNum r <br /> i-S 00 N orth Atiltv s Rea d .FEN V I R 0 N1 kfi E.N <br /> 11Y 84021115 17A!TP r)C0,1 p <br /> -,r,A 17. N'T <br /> Facility's Phone: (4 35 1 B,VA-8i G <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1 NDN K <br /> C.RA 1-1 f�Z A R DD W�, W INSTE LIQIJ I 01S. <br /> 0 <br /> J <br /> L <br /> 3. <br /> I <br /> 4. <br /> 14.Special Handling Instructions and Additional Informs lion <br /> T,f <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 res pe-ts 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 consign a ent conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement iden fed 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 /> Generators/Offerors Pdnted/7yped Name tiignature on Day Year <br /> 7- 7' <br /> —A 16.International Shipments <br /> 11 Import to U.S. El Export from U.S. Port ofentry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> IX I— Tcansperter I Printed/Typed Name Signature/,' Month Day Year <br /> 0 <br /> U) <br /> Z Transporter 2 Printed/Typed Narpe li,natur, Mo* Day Year <br /> 4- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEl Type <br /> El Residue Partial Rejection El Full Rejection <br /> Quantity 1:1 <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L) <br /> LL Facility's Phone: <br /> UO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R <br /> Z <br /> 0 <br /> 19,Hazardous Waste Report Management Method Cod(s(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 2. <br /> 1 71 T <br /> FD,.,,gynatec1 Facility Owner or Operator.Certification of receipt ceipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> nnt,d,ped Name p Signature Month Day Year <br /> V <br /> EPA Form 8700-22(Rev.3-05) Previous editions are bsolete. DESI&NATED FACILITY TO GENERAIOR <br />