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o- <br /> Please print or type Form Approved.OMB No.2050-D039 <br /> UNIFORM HAZARDOUS 1 Generator iD Number 2 Page 1 of 3.Emergency Response Rome 4.Manifest Tract] Number <br /> WASTE MANIFEST 0=5 19 4 5 5 6 7 JJ K <br /> 5 n rs arcC Mzu ress Generator's Site Address Id different than maEing address) <br /> ��� Gltl tih�i#t7T tf5 fElfSA 1�d1'Ntlltf»k101r[?511'R I ub Qt!bt#[1 ,W U$F6I51t, <br /> T=EEC Abe-L,7M UVECI AWY CA 09M ust*M UNC RTIONE CA S <br /> Generator's Phone -Len ATFI*tQ <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> S Designated Fad ity Name and Site Address U S.EPA tD Number <br /> LeWeL`.C@ Lk" ; 4 MMpe* CUR+,M4 9 7 CGf rd Wftw R'>rA 7r4LY(:A 953$ CAUMMUM <br /> Facilitys Phone <br /> ga. 9b U S.DOT Description Cn[.Iuding Proper SI-sppirg Name,Hazard Class.ID Number, 17 Conlairters 11 Total 12.Unit <br /> HM and Packing Group lif any!) No Type Quantity WLFM. 13.Waste Codes <br /> fi-OUL 5 P DGM <br /> (OM-SP 1 M[ERG 124 EWSF 352 <br /> w <br /> x 2 <br /> W <br /> 3 <br /> 4 <br /> 14-Siriecial Handing Instruchonsand didonati f <br /> Stt V Da?AM <br /> L—25�7 <br /> 15. GENERATOR'SfOFFEROR'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 Iabe[edlplacarded and are in an respects In propercondition for transport according to applicable International and national governmental regulations.If export shipment and I am the Prirnary <br /> Exporter I certify that the contents of this consigwwl conform to the terms of the attached EPAArknowledgment of Consent. <br /> I certify that the waste mimmization statement Identified in 40 CFR 262.27(aj(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOfferor's Printedrryped Name Signature Month Day Year <br /> I� N <br /> � 16.Inlemationa[Shipments <br /> f' ❑Import to U S ❑Export from U S Part of entrylexit <br /> Z Transporter s gnature(for exports only,: Date leaving U.S. <br /> W 17 Transporter Acknowledgment of Receipt of Material <br /> IE Transporter I anitedJyped Name!�J <br /> !'7 f! Signature / / Month Day Year <br /> CL <br /> Transporter 2 PnntedlTyped Name Signature Month Day Year <br /> F <br /> 16 Discrepancy <br /> 1 Be.Discrepancy Indicaton Space l Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b Afsemate Facility i or Generator, U.S EPA ID Number <br /> C.1 <br /> W Facility's Phone <br /> WC3 18c.Signature of Alternate Facility for Generatori <br /> Month Day Year <br /> U) 19.Hazardous Waste Report Management Method Codes i5 a.codes for hazardous waste treatment disposal,and recycling systems) <br /> LU p 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 /> PrinteCyped Name _ <br /> 1 / Signature) I Month Day f Year <br /> (�v l I I 1 11 { h I t t'�` <br /> EPA Form 8700-22 1Rev 12.17) Previous editions are obsolete. I TRANSPORTER COPY <br />