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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 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 ,!i }r;;;',t .,;;if s ; ' 4hp;"€ 0 J 3 6 3 9 4 7 <br /> GB F <br /> 5.Generator's Name and Mailing Address Generator's Site Address(ff different than mailing address) <br /> 0)4 : (rl iif lr1r}'af l:tOAA? 1l4i"i <br /> Generator's Phony+ <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i':;t 'r;ri ,f;'vii; i" 4,4A 1P' <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> �.;}ii'.)it'C 1t'}'•�''?!} a.:r}a}::l^iii�1.. `'�f.'€fv't..3:;;`.: .:,z � - .., i':%.� <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> t.;z?'€'s..iit'.:{t`,4n:' ..,r i?:: :; n`.r.:. rr :.;a: i 1, .,}3:c:r+.tjfi'i3E., , ::,;[ 1.°fii 51si <br /> rY <br /> 0 �. . <br /> Z 2. <br /> w <br /> 3: <br /> I <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> 113ii4 11 V# i11; } t. +:..`I <br /> 15. GENERATOR'S/OFFEROR'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 am 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 /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> ZI <br /> _J16.International Shipments <br /> r- ❑Import to U.S. ❑Export from U.S. Part of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporiper; d d yp d me Signature "r„ Y a MoIL <br /> D y, Ye r r <br /> fi wF_ <br /> QTransporter 2 Printed yped Name Signature lam.. Month Day Year' <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial RejectionRejection,-, <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU' 2. 3. Notice: State of California requires <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> generator to photocopy and mail to <br /> Printed/Typed Name Signature DT <br /> SC with 30 days: <br /> P.O Box 400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. Sacramento, CA 95812-0400 <br /> GENERATOR'S INITIAL COPY <br />