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Please print or type.(Form desigrted for use on elite(12 pitch) ewnfec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gyrator ID Number 2.Page 1 of 3.Env#wq Res Phone 4.Manliest Tracking Number t p r <br /> WUTE MANIFEST C'.ARO0001S560 1, 800-169-Ori-9533 00091,r 619 MYY <br /> 5.Generators Naim a d Mailing Address Generetors SIN Address(If diltererd then ireivng address) <br /> tdounta to Vallt--y E rpr&,s Cc) "()tterat" 1.019 Bessemer Dr. <br /> Masttl.r+k:.t . (:A, '..4t,3_it� hiaaitrc.:1, CA, "136 <br /> Generators re: f;00 640- 9!i:4:3 <br /> 6.Tr porter 1 Company Nave U.S_EPA ID Number <br /> HCJ & k:K6if*XRJ:N( ;iMV1(X (-'A�(000176826 <br /> 7.Trarwperter pan/Nam U.S.EPA ID N <br /> .r, NIAW, <br /> Designated Facility Name and Site Address U.S.EPA ID Number <br /> RHO C'HID4 <br /> 42h i:5'.(!i AVIw:N1JIr' <br /> ENGIrE'WU()J.i. C'A 90301 <br /> FacII sPhons: 312:3 'Pith 6233 f'AD008:3644:0 <br /> ga. 9b.U.S.DOT Description(including Proper Shiplkg Name,Hazard Class,ID Number, 10.Containers 11.Total 12.lust 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Q,a,by Wt,/Vol, <br /> 1. t 1�0i. @ley:>Lr, �IZ/ItOk htlUl:lt.t ,colu�l.J1'1,y. k , 1'L4J t I)00:2 1.41 <br /> Z 2. h_., it�t, 1:1 i ijLc�3;3uc1'fyllLLt.lv,; A/:iit. 01:V'. j}f10_i 'Ji;? <br /> L9 X `3. .I . P(411 t I. <br /> 3. <br /> 4. <br /> 14.Special HmxUq Instructions and Additional Information <br /> 68810'1 00: EFt 4 1.40 <br /> 14y".4F'. I?J OPEIt. PI-VE. till-I. 7'0 tic." VII k H:td(, tivr: t+10#;4:1'1 70. <br /> 15. CENERATOR'31OFFEROR'S CERTIFICATION: I hereby declare that the contends of this consigrwrart are kdy and accurately described above by the proper shipping mere,and are classited,packaged, <br /> marked and carded,and are in all respects In proper condition for import according to applicable International and national govenmenei regulations.If export shipment and I arta the Primary <br /> Exporter,I cetiRy that the contents of this consignment conform M the terms of the attached ERAAckno~ent of Consent. <br /> I certify that the waste mlnlmkadon statement iderdled in 40 CFR 26227(x)(if I am a large quantity generalo*crib)(ifl ern a small quantity generator)is true. <br /> Ge nerator's106eror's RinteorTyped dame Signature i Metier Day �r <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Expod(non U.S. Pat of entryleadt: <br /> Transporter signature(fa exports only): Date leaving U.S.: <br /> W 17.TransparterAdmawledgmeritof Receipt of Materia <br /> plansporler 1 Prmted(i Nacre SiVaIN t Yfar <br /> h1>y('rjo-) )LLfscc I ' <br /> Tyansportar 2 Printed/Typed Nam Sig ---ti7 Month Day You <br /> 18.Discrepancy <br /> 18a.ascrepency Indication Speoe ❑Quantity ❑Type ❑Reser ❑Partial Rejection ❑FuN Rejection <br /> Maadest Reference Number. <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility a Generate) Mordh Day Yaw <br /> a <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and mcyctrg systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Cer6Gcatiat of receipt of hazardous materials covered by the mw&st except as rated in Rom 16a <br /> I t --Prim. 1\in YA2 //.,I I <br /> Signature <br /> EPA Form 8700-22(Rev.3-05) Previous edAbtsare obsolete. DESIGNATED FACILITY TO GENERATOR <br />