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Please print or type.(Form designed for use on elite(12•pitch)typewriter.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator 10 Numbe, 2.Page 1 of 3.Emergency Response Phone 4.Man.iteat Tracking Number
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<br /> WASTE MANIFEST FLE t,.ire ; ?:' ., s;5( '� �
<br /> 5.Generator's Name and Mailing AddressGenerator's SiteAddress(if different than mailing address)
<br /> Mark,a�
<br /> '?,�, L,>di CA
<br /> Generators Phone. �•-
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> 7,Transporter 2 Company Name U.S.EPA ID Number
<br /> 6.Designated Facility Name and$119 Address U,$.EPA ID Numbei
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<br /> Ftidi tys,Rhono:` t r 1 C.R•0 6"i 'l.'•irk 1 '
<br /> ga. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10;Containers 11.Total 12.Unit 13.Waste Codes
<br /> HM . and Pacing Group(if any)) No. Type Quantity WWol.
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<br /> iHIS WASTE STPN QL;:�t.IFIEU
<br /> 11nt .: ►r. T M UNTSAT'fF
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<br /> c' ?is�31�i�f►f�:T01`�Vr�-CJLXJ� HAS T1�1 c�tEGESSARY : UN 6 201
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<br /> OUR i:?A NU�11Q�ft IS GATL3SOOJ 3352 CNV RO
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<br /> 14.Special Handling Instructions and Additional Information �+1 , 1 J
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<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 intemational and national governmental regulations.If export shipment and I am the Primary..
<br /> Exporter,hc6dify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent,
<br /> I cerfify that the wade 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 /> non erato er s Printedfrypad Name Signature Month, Day Year..
<br /> t—z 16.International Shipmentsy
<br /> IL— ❑Import to U.S. ❑Export from U.S. Port of entry/exit:
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<br /> Transporter signature for exports only): Dale leaVin G'S.:
<br /> W 17,TransporterAcknowledgment of Receipt of Matvals�
<br /> Transporter i Printed/Typed Name r ' a Signature r on ay ear
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<br /> ZQ Transporter 2 Printed/ryped Name r gna ure on a Year
<br /> 18.Discrepancy
<br /> 1.8a: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
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<br /> Facility's Phone:
<br /> W 18e.Signature of Altemate Facility(or Generator) Month Day Year
<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20:Desigriked Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 189
<br /> Printecirfyped Name Signature Month Day Year
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<br /> EPA Form 8700.22(Rev,3-05) Previou�,�rifCiorls are obsolete.: ;,�.- DESIGNATED FACILITY TO GENERATOR
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