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o!..........w' 4 Cnrm A—; —A f-- — .1if. 11 9—iflhl hinawritar) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous eclitions are oi:isoie U11=1111ir-rim 1 Un 0 11,41 1 IML- %0%4r- 1 <br />'1-1i— - — - , V ,, I. , "i �, <br />,,,, r, . . ..-- — --- — -.— '. - " . -, •,r - - ....... <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />(A <br />Page <br />3. Eme W ency " Response Phone <br />4. Manifest Tracking Number V0 <br />Sao <br />WASTE MANIFEST <br />5. Generators Name and Mailing AddressGenerators Site Address (if different than mailing address) <br />STO..'KION RIABEIR 111-13 C0 ING <br />rz IN F i"Ictcl "Id <br />CA '35-236 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />q <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address ;��D Number <br />3,11 WT -Fc, OF PFATlY HWY 9zl <br />B qal r T Y NV 8'300,,�, <br />NV 01 0 t, <br />I <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt Not. <br />Yu <br />V1 -44 -.1443-E"ff Etl tF <br />Z <br />LU <br />2. t <br />3. <br />LAS] E <br />HZAO' is <br />NOiN CRA ARD <br />P <br />5�" <br />3,- <br />�AVKIRBENT AND MR -1 <br />LQ <br />4. <br />14. Special Handling Instructions and Additional Information$,•gyp t; <br />iE'A HR E-PlERGENCY 'SAFETY-KLEEN CCN V4r-f21T #94138" <br />r-�k 'ILI 1�r4PEUERS GIS WFUM91V <br />15. GENERATOR'SIOFFEROFVS 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 labelediplacarded, 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 />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ff I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />-j <br />r— <br />16. International Shipments <br />El import to U.S. El Export from. UJ.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17 Transporter Acknowledgment of Receipt of Materials <br />Transpo r I Printedirryped Name. Signature Month Day, Year <br />0 <br />CL <br />CA <br />a <br />Tran iter 2 PrInteVyped Name ,,"Signature Month Day Year <br />Discrepancy <br />I18. <br />18a. Discrepancy Indication Space EJ Quantity Elype EJ Residue F-1 Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Aftemate Facility (or Generator) U.S. EPA ID Number <br />.4- <br />Facility's Phone: <br />0 <br />Uj <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />16? <br />`19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />U) <br />UJI <br />0 <br />—7— <br />2. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printedfryped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous eclitions are oi:isoie U11=1111ir-rim 1 Un 0 11,41 1 IML- %0%4r- 1 <br />'1-1i— - — - , V ,, I. , "i �, <br />