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Please printor type.(Form designed for use on elite(12-pig ,4pewriter.) - Form Approved.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_
<br /> 5.Generator's Name and Mailing Address enerato s ile ress(if different than mailing address)
<br /> % , fi 1. STI .( AY)
<br /> iS ST St�iULTE
<br /> Generators Phone
<br /> 6.Transporter 1 e „ U.S.EPA ID Number
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<br /> SHOP +�. fINC. Y
<br /> 7.Transporter 2 Company Name "' U.S.EPA ID Number
<br /> $ Designated Facility Name and Site Address,
<br /> }g g .y¢� j U.S.EPA ID Number
<br /> 4 A+�E r�rF.F 4 A.LI
<br /> 1iT, yppTER ig /E[
<br /> M Tit 3� 4
<br /> R,57
<br /> Facility's Phone::$J6� 51v0
<br /> ga. .9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit
<br /> and Packing Group Nan 13.Waste Codes'
<br /> Y)) ._ . „ ;�. ,.No•.-; -Type Quantity Wt#ol,
<br /> HM 9 P C ;, ..
<br /> 1. .
<br /> O r " a,
<br /> 7 777777=
<br /> 'W'^^ 2• q�F�47YG TE-"ONS.I1fi4 'f 1 'N 7!� M;'s^eS Ff
<br /> 3: �Ai�A 3 'Afdl TE ! P 2$ 362
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<br /> 4.
<br /> ,3,.� l o, c.. ,d:Dt,J wu.y F,�,. c, .t>j.,. :.�s, �o,.�_ •:t,:_. 7_,ti:' i t _ „.
<br /> 1 Speaal Handkng Instructions and Additional Information
<br /> i J
<br /> 15 GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of th s.consignment are fully and accurately described above by,the proper shipping name,and are classified,packaged _
<br /> rriaiked and Ia6eledfpiacarded and are m all respects in proper cbnddion for transport according to applicable international and national governmeh 'I regulations.ff export shipment and i am the Primary
<br /> Exporter I certify thatthe dcdents of this c6nsignmeht cenfomi to the temis`of the attached EPAAckndwte Q *--
<br /> "A
<br /> of Consent
<br /> e "A
<br /> k Qrtify that ttfewaste minimization statemerit'id6fiMed int 40 CFR 262.27(a}'(if i am a large quantity ger> j`r(b)(if$ain a small quantity g er�tor)is true:
<br /> Gen oto slOfferor's'PnntedRypedName n T r Month Aay xear,
<br /> j 6rinte ationa hi n ria, . ,
<br /> Z ❑Import to U S: ❑Exportfrom U.S Port of entryfexit
<br /> Transporter signature(for exports only): _ ?; Date leaving U.S..
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<br /> 17.Transpofter'AckhoWd-dgmentdfReceipt ofMat6dals
<br /> a Transporter 1 P ntedltyped Na Signature"
<br /> Month Day Year
<br /> IA
<br /> aM[ "Transporter 2 PdntWyPed e °, ;a ., Sign th D.., r.
<br /> a }.s+{,y�.,•:1.„ isi�':..�iw sa .r!M.�4,.i.,i•lA.0 =.. ,,..+ .. ..., , „- » , ., '
<br /> 18.Discrepancy
<br /> 18a Discrepancy Intlicahon Space -ej
<br /> ❑:Quantity ❑Type El Partial Rejection ❑Ful(Releckon
<br /> 1 .
<br /> s _ Manifest Reference Number:
<br /> 18b.Aftemate Facility(or Generator) U.S.EPA IDNumber
<br /> t7 �.
<br /> � Facility's-
<br /> Phone: •-
<br /> W 18c Signature of Ahemate Facility(or Generator) - Month Day
<br /> Q _ u
<br /> 9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) - Notice:New federal form. State of
<br /> 2 3.
<br /> California requires generator to photocopy
<br /> and mail to DTSC withiu,30 days:
<br /> 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted'in Item 188 P.O.BOX 400,.Sacramento,CA 95812-0400 '
<br /> PrintekUTyped Name Signature .
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete.
<br /> GENERATOR'S INITIAL COPY
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