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ry�w.. ii <br /> CUVMI'�� <br /> Form Approved, <br /> Please print or type.i f orm designed for use on elite(12-pitch)typewriter.) OMB No.2050 0039. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A C 0 0 2. 6 2 5 2 (800) 424- 4300 003883264 JA <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> JUAN RARAJAS <br /> 3570 FAST MINER AVENUE <br /> STCXXTON CA 95205 <br /> .___. .. . . (209 461- 1006 <br /> Generator's.P-hone: <br /> 6,Ttahs sr3er 1 Company Ne // U.S.EPA ID Number jJIf <br /> C <br /> VVI l l..- Cy® d . <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faclllttyy Name and Site Address U.S.EPA ID Number <br /> a-7-MIC:AL WAST-E MARAGEMEN'T,iNG <br /> 35251 OLD SKYLINE.ROAD C A T 0 0 0 5 4 0 1 1 7 <br /> KET'fL.E94N CITY GA M23 <br /> F (554;! 38h• 471 '1 <br /> Facility's Phone: <br /> 9a 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> 1 iUN3077 RQ E14MRONN(ENIALL.'i'rf'AR[r/USSUEGI-ANCES, <br /> o X SOLID,N.n S 9,111,(LFAD) - - - -- - <br /> (.,A2a8383 <br /> LU 2. <br /> LU <br /> c� <br /> 3. <br /> 4. <br /> oo <br /> 14.Special HandlInsstructions an Additional Information <br /> 1 <br /> 15. GENERATOR'SIOFFERO ' 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/plagilded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify th a contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> certify that th ste 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/Offerors Printed/Typed Name siginiture 0, r Month Day Year <br /> cc <br /> 16.International Shipments I ort to U.S. ❑Export from U.S. Port of entrylexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w <br /> 17.Transporter Acknowledgment of Receipt of Mat eri <br /> Trans er 1 Printed/Typed Name .� � Signature Month Day Year <br /> ° 2. 0t5 <br /> Q Tra rter 2 nnted(ryped Name Sign Month Day Year <br /> po <br /> o= <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> V(N Mi s r TL- <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL 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 /> 01. 2 3. 4. <br /> 1. <br /> 1 <br /> 20.Designated Facili Owner or Operator-Certification of rece' t of hazardous materials covered by the manifest except as nded in m t Ba <br /> PrintedlTyped Na Si nature Month Day Year <br /> 136 <br /> EPA Form 8700-22(Rev.3-05) Pre us editions are obsolete. DESIG F LIN TO DESTINATION STATE (IF REQUIRED <br />