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Pleat print or type.(Form dei ed for use an elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11.Generator 10 Number 2.Page I of 3.Emergency Response Phorte n Traddrill Num.bw <br /> WASTE MANIFEST Cf�P 113010 1 i I,jc-10 00868 <br /> 7 1282- JJK <br /> F15,Generator's Name and Willing Address GsneraloftSidAddress(ii different than mailing address) <br /> GenerebesPhone: <br /> 6.Transpoft 1 Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U-S.EPA ID Number <br /> B.Design aW Facility Name and Site Address U.S.EPA ID Number <br /> six3 0 'Cil-va On VY-I <br /> on.CA 835' <br /> Facilly's Phone. <br /> 10 11.Total 12.'Unit <br /> ga, 9b.U.S,DOT Description(including Proper ShpftV Name,Hazard Class,ID Number, .Conlair.a' 13 Waste Codes <br /> HM and PackIng Group(If any)) No. &', o oopw Y -r-Ap- I.., <br /> 2. <br /> is 7 <br /> CD <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Intonation <br /> Cr.4y We2l-t,-ET,(" I <br /> J17 11 <br /> Kande--s tr,b---:40h,-4r;z-iPr--!cur-16 wtr-nj lit rP;:-S RGr;-;,I <br /> 15. GENERATORISIOFFERORS 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 labelecliplacerded,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 certity that the contents of this consignment conform to the terms of it*attached FKAcknowledgment of Consent. <br /> I certify that the waste minimization statement IdeWed In 40 CFR 26227(a)(If I am a large quantity gator)or(b)(if I am a small quantity gene <br /> Generaloft,1011larces Printeffyped Nam generator)is true. Month Day Year <br /> -,z <br /> -j 16.International Shipmerits El Import to U.S, El Export ft;U.S. Port of antrylaxit: <br /> 9 Transporter signature(for exports only): Date leaving U.S.: <br /> Uj 17,TransportarAcknuiviscIgment of Receipt of Materials <br /> jj Transporter 1 PrintedlTyped Name Signature --P Month Day Year <br /> 107 1 <br /> Ott <br /> Q rransporter 2 P*ftdfTyped Name Signature Month Day Year <br /> oG <br /> 4C <br /> I18.Discrepancy <br /> 18s.Discrepancy Indication Space ❑ quantity OType EJ Residue ❑Partial Rejection Elull Rejection <br /> Manifest Reference Nuwnber. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> 114. Facility's Phone: <br /> 18c,Signature of Alternate Facility or Generator) Month Day Year <br /> z <br /> 2 19-Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> T,% <br /> 20.Designated Facility 4er or Operator:Cerlillicallon of recelpt of hqVous materials covered by to manifest except as noted in Item 18a Mth Day Yew <br /> Printedfryped Name f I Signature on <br /> .......... <br /> EPA Form 8700-22(Rev.3-05) P16vious editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />