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f.;MIR a copy to., DTSC,P.O.Box 400,Say iii 30 d s <br /> Please print or type. Fonn designed for use on elite 12-itch writer Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1. to ID Number 2 Page 1 3.Emergency Response Phare 4.Mangled Tracking Number <br /> WASTE MANIFEST (/ i <br /> 5.Generator's Name and Mailing Addre Generator's Site fi n address) <br /> a Generator's Phone. d ` <br /> 6.T "v t Co vmie rIonmentaI ices <br /> 7.Transporter 2 Company Nance U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address ), Inc. U.S.EPA ID Number <br /> Smith v , ser <br /> CA S <br /> Facillift Phone: W- 7418 <br /> gar 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Numb, 10.Containers 11.Total 12.Unit 13.Waste Cates <br /> HM an Padcin9P(d any)) No. Type quantity WLArcI. <br /> ;WIT <br /> ell Z=1 DOE, <br /> t� <br /> d.J f w�I <br /> 90 <br /> W I is s f 1 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional infamnaf on 4 <br /> 15. GENERATOR11OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully end accurately described awe by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are In all rests in proper condition for transport according to applicable Intemetionel and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the teme of the attached EPAAdmowledgment of C&senL <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(d I am a large quantity generate or(b)(If I am a smog quantity generator)Is true. <br /> Genera pg�}to Printedfryped Name }e f[ Signature ® { { R Day Year <br /> 18.international Shipments Import to U.S. ❑Fxpot from U.S. "Pat of entry/ex�� t r <br /> Transparter signature(for exports only): Mweaving.U.S.: <br /> 17.TranoponerA ant of Recelpt of Materials <br /> Trenspoiter t ped Nam sign atu Do , Yea <br /> s <br /> Tre—netiorW212drited/TypedNamf Mort Day You <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Fall Rejection <br /> 18b.A temate Facility(or Generator) U.S.EPA ID Number <br /> is <br /> FacRlys Phare: <br /> Itis.Signature of AAitemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management McBrod Cafes(i.e.,codes for hazardous waste trebtment,disposal,and recycling systems) <br /> C 1. <br /> 20.Designated Facility Owner or Operator.Certification of 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 obsolete. DESIGNATED FACILITY TO GENERATOR <br />