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- 4 <br /> 1. <br /> P s,%prinFor ype.(Form designed for use on elide(12 itch) p wr ter. ;` <br /> FonnAppraveii:� <br /> ' UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Enargency Response Phone 4 Mantteef Trxking umbar 7. <br /> WASTE MANIFEST �flL�'�i�r'snir' } gym3.i��» 3§•:�� 272343 �. <br /> 5.Generators flifts and Mating Address 'Generators Site Address(if different than mailing address). <br /> LTIEUa.!£CORP An.P. E <br /> 41 <br /> WOCKIDN'CA 9= <br /> Generator's Phone: W11*2002 <br /> li.Transporter 1 Company Naive <br /> .. U.S.EPA ID Number, , <br /> 7.Transporter 2 C+i 9f117$7 r7S) <br /> Pant Name U.S:EPA ID'Numbar <br /> 8.Dark It dFacd<dy Name and Site Address7, UrU.S.EPA ID Number <br /> �'!� r <br /> #SMti, t E�yIR®�iMENTAL` <br /> :.TME�tT` <br /> FacN s Pham �.. <br /> - i <br /> 8a U.S.DOT Desgptrorx sxg ProperSMpplixj Name Flerard Ctess ID Number 10 Zontafners 11.Total 12::lnit 13.Wash Codes <br /> _. .. <br /> N <br /> acrd Pac ft_ Cif arry)) ... o Type Quantity WtAlbl. f <br /> lY X Fd73F!RIXP4 t 1lOW' ASTc 3 l,it? tL'Y in tt) tT r a <br /> � . j <br /> tu <br /> ( r <br /> 3. i <br /> 4 a <br /> 14.5pertial Handling Instructions and Additional httannatian t . <br /> 15.'GENERATOWSfOFFEROR'8 CERTIFICATION:t hereby declare that the contents of this,consignment are ttdly and accurately described above by the proper ship <br /> pkV trema,and are classified,padreged, <br /> Marked and labeledplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national gov mmentai regulations.if export shipment and I am the Primary <br /> Exporter.I ce*Bal the cadentsof tlxts consignment conform b the terms of the attached EPAAdwawkedgraeftt of Consent. { <br /> I certify that ffrs waste minimization statement identi M in 40 CFR 26'1.27(a)(if[am a large quantity generator)or(b)(df am a smog quantity generator)is he, ; <br /> Generaters/Ommes Printedfl i' <br /> YID Name Signature Month Day Year, <br /> - -�' 'i,:r. ';;..'w. f 1..00-�.- �, •y_ .,�- tl <br /> -r 1&International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. •Port of elyf a; Tr <br /> Transporter sigrxatrae,(for expels adY) ' t�ate'leaving u.S.: <br /> u 17.TmnsporferAcknoWedgmentofReceipt ' <br /> Trans err I <br /> Y 1 Name Signature d/ , f' Mi <br /> y' - <br /> s <br /> oe <br /> 4 • t <br /> Transporter 2 PxinteM/ ped Nana Signature Month Day Year i <br /> 18:Discrepancy, - _....._-..._..-...�_... <br /> 1tta.Discrepancy maim Space D cw dry ❑Type ❑Residue <br /> ❑Parttel Rejection ❑Ful Rejecuorx fr <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> . FaciityrsPhone: <br /> j 18c.Signature of Alternate Facirdy(or Generator) <br /> Month Day Year <br /> { <br /> r !i. <br /> 19.Hazardous Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recydtng sys�rns) f, <br /> T7 <br /> t r 2• <br /> 13. <br /> 20.Designated Facility Owrxer or2pefa r.Certification of receipt of hazardous materials covered by the manifest except as noted in hem 1 Ba i <br /> Prfnledfryped Name /'f 1— Signature r f Montf!> y 7: Ygar, <br /> 1` i' r r <br /> 1 Form 8700-22(Rev.3-05) Previous editions are obsolete, TRANSPOR iER'S COPY <br />