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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.MepifestfTracNingAwnb <br /> WASTE MANIFEST Al i)130441"ig "t' `` -3 G B F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> I'M-SH INW..aVA IONS CALIFORNIA <br /> 1731)1-*. HWY 99 <br /> Generators Phone:. . f;i i ty,'-KION,(:A 9 b''15 <br /> 6.Transporter 1 C1 anji m ' ` U.S.EPA ID Number <br /> ,F , <br /> 7.Transporter 2 Company Name I U.S.EPA ID Number ` <br /> 8.Designated Facility Name and Sit eis -Sftlt1tj 1 l6itlti, dft U.S.EPA ID Number'' <br /> 21S'11 (;ENTURY E NlVIR0P MENT1Al.64(iM'I 0-I'EVi-i!.P, I.1 i:, <br /> Nsysat3n�t :�ls <br /> 2005 Itt'r`.V1P!_ANii1;a OR.PAST <br /> Facility's Phone:, 'EMIR.17Y,T.101 <br /> ga, 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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> a1.�A0 <br /> LCKJM TITRATE) <br /> i.%Y�;?4'if'�P,1�c1,.7Nr{�jt,A::�(11t,!';if'?Ni,}1, I�(,il(t,[/�Mi`./lt�I�ltL}�!•{'s�I_f!+?f'r1Sl";�', y t);- r a c` <br /> w <br /> LU <br /> 2' <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> LABT'A(;K#1 AMlUONlILIM HYDRt:'X10F. E:RG#-154 <br /> EMERGENC;'Y CO11 fl"AC:T'. STT VF:M <br /> 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, <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 /> Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> T... ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a <br /> Z Transporter 2 6nledrryped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ..r <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 <br /> Notice: State Of California requires <br /> 1. 2. 3. <br /> generator to photocopy and mail to <br /> i20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a IJTSC with 30 days: <br /> PrintedlTyped Name Signature P•O BOX 400 <br /> -_ I Sacramento, CA 95832-0400 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL l;Ur t <br />