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71 4 <br />Please print or type. (Form designed for use on eli (12 -Ditch) tvoewriter.l <br />P- Annrn,iol4 nhAD AI.. on[n nnnn <br />EPA Form 8700-22 Rev. 3-05) Previous editions are solete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1, Generator ID Nu <br />bar f _ h}. tt <br />t�.,i t- 1-,24JCJiRv ( <br />2. Page 1 of <br />3. <br />3. Eme�f�Qe;�ncy Response Phone <br />qq <br />1_..;^; , <br />4. Ma ife Tr cki g Number <br />�� <br />5. GetGenerators Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />1147 E MA 1 sN LUTHER <br />.tT.N <br />r3.11.C! 6 type <br />CP 9 512105 <br />Generators Phone: al? <br />6. Trans orter 1 Company Name <br />U.S. EPA ID Number <br />SAFE. i Y ;til...T:.:�i .I 7 W d Ey <br />f� � <br />T,irn Y V _; ltiTllfilJ �.; _7',:•4:i <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U -.S - ID NumberC PFETvo LE~d �.TMMS, a4IC'. <br />L�ttaQt 88T14 9TREE7 <br />CA 95626 <br />491 <br />Facility's Phone: <br />ga, <br />9b. U.S. DOT Description (including Proper S <br />ipping Name, Hazard Class, ID Number, <br />10. Containers <br />11 Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />JX <br />1.1`II�N RCR I ' 11 t1s 3 <br />;�3P'.,Z,.)..R I.slQkJIDS <br />LIT: <br />� <br />P <br />P2 <br />(I_LIBRICATINC' 01L <br />WATFIR) <br />.' ', <br />W <br />z <br />W <br />2. <br />c.7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Inform <br />ition SK 1311 11 P*20493-10C` 4 549-77668 3-7 1838 eau .H <br />r=4 HIR r-.{;7ERG1-.NCi+ iil-AIN-66--1760 <br />(SAFETY-KL.F_l~Rl --� CONTRACT #94138, <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: <br />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 resp <br />cts 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 <br />ant conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement ide <br />tified in 40 CFR 262.27(a) (if I am a large quantity generator)_or.() (if I am a small quantity generator) is true. <br />Gene rat s/Off erorp'f$/PnntedfTyped._�q <br />d Signature { Mon ay Day Year <br />y9 <br />d <br />16. International Shipments <br />❑ Import to U. <br />/ <br />❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): <br />Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />V <br />Transporter 1 Printed/Typed Name <br />Signature Month . Day Year <br />y <br />aTransporter <br />2 PdntedTryped Name <br />Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quantity <br />❑ Type ❑ Residue ❑ Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />Facility's Phone: <br />In <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />!R <br />Z <br />N19. <br />Hazardous Waste Report Management Method Cod <br />(i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W <br />1 H14i <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification If receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 Rev. 3-05) Previous editions are solete. <br />GENERATOR'S INITIAL COPY <br />