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Please print or type.(Form designed for use on elite(12-pitch writer.) 7)43,26'3619 V PPW 3f.101.1 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 [ A 1-0 0 0 3 b 9 1 0 2 1 i000)A a 3 -;ILA 0556 943 FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> DT F 15tvK*#.ofw LK: <br /> 2q2C*W Warilmotost Street 25,26W washi"� tvrk"Afeet <br /> Stocktow CA 95203 llitechtar%:�A'95703 <br /> Generator's Phone.42,091320-•<t"1. At M-,Uoug INA! <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> cheall Haltor% Sok-Oresrff A V 0 3 4 -3f F1 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 0aim 11-11"ors Soft Jose LL(, <br /> 021 fterwevsa Road 1* a A <br /> 1`4pr1p <br /> ,Ise.(A <br /> cli one: 44044 44 A 426'-J <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 1 01014-WRA HAZAROMS WASTE %KLD-(fLASTCORTAMING: <br /> 0 <br /> LU <br /> 3. <br /> 4. <br /> J <br /> 14.Special Handling Instructions and Additional Information <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 EPAAcknowledgment of Consent. <br /> certify a a 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 /> Generator's/Offeror's Printed/Typed Name signaE—re on Day--75—ar <br /> =-J 16.Intemational Shipments <br /> I-- El Import to U.S. Elaport from U.S. Port of entry/exit: <br /> Z Transporter signature for exE2rts only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> -7— <br /> Transporter 1 Printed/Typed Name Signature Month Day ear <br /> 0 <br /> Z <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> bg <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> IZ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> UO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R- <br /> Z <br /> 0 <br /> V5 19. Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 <br /> UJ 1. 2. 4. <br /> ij, . 1 -7 <br /> 20.Designated Facility Owner or Operator.,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 0#60 tiayb#14 hof tho ap;K84"latai Pevffltfol and will'14cipt the waaf,the sterwarlog is shappifr,'° <br />