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Form Approved.OMB No.2050 0039 <br /> g writer. 4.Manifest Tracking Number <br /> Please print or <br /> type.(Form designed for use on elite(12 pitch)type ) 2 Page 1 of 3.Emergency Response Phone ® .,. � i 4, 6522 GBF <br /> 1.Generator ID Number EVi <br /> UNIFORM HAZARDOUS LA1 Int} <br /> WASTE MANIFEST Generator's Site Address(if different than mailing address) <br /> 5.Generators Name and Mailing Addresswrow '.I C Y11A�TF Rf:roVr.fty WE- <br /> 4554 1:-i lJORAD0 J = i <br /> ,iT()C'KT.0N,CA 913206 <br /> 204 4-0i(R) r U.S.EPA ID Number <br /> �> U <br /> Generators Phone: ; i}ili.W i t;7 t4 <br /> 6.Transporter 1 Company Name 1Y, 1 <br /> t��t ;ii:.;t1•i vA[I FY:'4D�+.i*Tk.(1t1 II'3�� , U.S.EPA ID Number ,ii <br /> 7.Transporter 2 Company Name `\0 u�`�, - <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address ,l-WKpj4Lj-e,7 t•N")it)t VA,1 i t• <br /> !{t?�1NF'tf i� tLtJ(.K FCL►. <br /> 4 tk3"`•a1 CIf f7 <br /> Facility's Phone: 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Tyle Quantity Wt.Nol. <br /> HM and Packing Group(if any)) r6.1 1_j <br /> 1. tX.?N-F?I;RA H/►:'ARrKhlKi WA�:t�t: ^:cat tt� - <br /> p �8^..c%RF�.f TffS R SII <br /> Z 2. <br /> LU <br /> c� <br /> 3. <br /> 4. <br /> 14.Sr�ecial.J t.ageing__IppsWctions and Additional Information <br /> a_ : t)i AtiSr•..4011EN r:S 6 t)tt_ F:}tf�if t 7 i <br /> C{1NT`l1Ci Rtt.JtR00 <br /> 1 <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 international and national governmental regulations.If export shipment and I ani the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste 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 /> Signature Month Day Year <br /> Generator'slOff€fox's Printed/Typed Name <br /> 16.International ShipmentsImport to U.S. Export from U.S. Port of entrylexit: <br /> Date leaving U.S.: <br /> Z Transporter signature(for exports only): <br /> Ll 17.TransporterM07. Ya Acknowledgment of Receipt of Materia - "' �� <br /> Transporteyl P'ntgct/T me r Signature'" <br /> y <br /> / ,. J / <br /> CL r, <br /> co <br /> Z Transporrer 2 Printedffyped Name Signature Month Da ear <br /> Q <br /> N <br /> 18.Discrepancy I <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue LJ Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J_ <br /> V <br /> Facility's Phone: Month Day Year <br /> CS 18c.Signature of Alternate Facility(or Generator) <br /> a ., <br /> Z wwv rrv�r v <br /> i9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> CA <br /> 1 2. 3. Notice:State of California requires <br /> gernerator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item I DTSC with 30 days: <br /> Printecir yped Name Signature P.0 BOX 400 <br /> C42� pSQ1'f_AA <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> rCIJCQATAR'C INITIa71 (-(IPV <br />