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aw,4ytaiC a cwy to: O 5~,P,O.Box 400,-%aMM*rdM CA 25"2 tttOUii#'€30 ory;° —
<br /> Please print or type.(Form designed for use on elite(12-p,_ ,typewriter.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.'mea`envy Response Phone 4.Manifest Tracking Numgber
<br /> WASTE MANIFEST , i '. .424.43 Q 0 ,�! JJ K-
<br /> 5.Generator's Name and Mailing Address K 1�fif co, ess(if different than mailing address)
<br /> RECrIVM.
<br /> Generator's Phone: it O 1
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> 7.Transporter 2 Company Name — U.S.EPA ID Number
<br /> PERMIT/SERVICES I
<br /> 8.Designated Facility Name and Site Address ,• y . M U.S.EPA ID Number
<br /> .1 f Rmk Road
<br /> t xbr '-'-mckym CA 11574 t.
<br /> lacili 's Phone:... "f I 11 111 J-
<br /> 9a. 9b U DOT r)esc.ription(including Proper Shinplog Name,Harm d, .ss,ll)Number, 1C.Containers i1.rota! 12 snit I
<br /> HM od Pack'i; t o(if any)) "—— 13.Waste Codes
<br /> No. rype Quanht
<br /> !TrLU
<br /> �r I
<br /> CD
<br /> kaftis'ai vil ra x
<br /> :/�I �''� i ,.- :'tet+i%,i.�f /t:�, r .'�LIZ./ 0,7
<br /> �. ' I /• ' ( JI +
<br /> —C-
<br /> 14.
<br /> 14.Special Handling Instructions and Additional Information
<br /> a CIERTIFIt♦AT y J , ,aant,.;of this consignment are fully and accurately descrihr i oro by C is prop i shp,pi;i,name,and are classified,par!.aoad.
<br /> a, d ,d are in all ,y::, ,a °;port 3ocording to applicable interoational i, ti: ime;rNl h�ns.tf exp,rt!, ipment and I am the Pdr,
<br /> 3f rhe atta;;hed EPA A&..c :oInt t f('
<br /> u n stater, ,R d F n2 21(a)N i am a large qui,:;`y) ) '19iui'l, merat• 'r« h
<br /> IGen ,ame Synar,, Month at t
<br /> J 76-1
<br /> apo, `ruro U ,f entr 5g...:
<br /> iransp-ter sign •nc' )ate leaving U S.: –
<br /> w 17 ;porter/ v receipt 54Fc+gals T — _
<br /> Trans orterl f �, _ �. ��..�, —.�
<br /> p ame in tui Month/ Day Year
<br /> CL
<br /> Q Transpurta;2 Pri ; 7c Na r Signatuid Month re vr.
<br /> 18.Discrepancy
<br /> 18a.01screpancv: .. '4
<br /> I I Ouantity .� '�i ype i. 0 Partial Full Rejection
<br /> 18b.Alternate Facility(or Generator) —� f—.—. ._ a _ U.S.EPA ID Number
<br /> J
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<br /> Facility's Phone:
<br /> w 18c.Signature of Alternate Facility(or Generator) — Month Day Year
<br /> Q
<br /> Z
<br /> Uj
<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 0 1. 2. 3. T-
<br /> 20.
<br /> Designated Facility Owner or Operator.Certifipatlnn,if receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed/Typed Name Signature ,— Month ay Year
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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