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Form Approved.OMB'No.2050-0039 <br /> d for use on elite(12-pitch)type r.) <br /> o type.(Forrindesiiii bar <br /> ous 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone ani <br /> �V t�ORM HAZARD <br /> 510 FLE <br /> C 00665 -,� 373 <br /> COAL UU10 f.118Z 040 76 t 140 <br /> S <br /> WASTE MANIFEST <br /> i es Address(it different than mailing address) <br /> 5.Generator's Name and Mailing Generator Site <br /> sod(tov,St o 70,0 4A.6 <br /> .,e"ervickat <br /> CA 9`V-',1,'3 <br /> Genirafor's Phone: EPA ID Number <br /> 6.Transporter I Company Name <br /> !ejOik) k-l-v tow, <br /> U.S,EPA ID Number <br /> 7.Transporter Company Name <br /> ,-I r <br /> uk U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> o!"i.)V&�U`vlrl i r0i <br /> Facility Phone: <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 /> ±-M and Packing Group(if any)) No. Type Quantity Wt-Nol. <br /> v. <br /> 1. r4 ci i SCAd�uqcrd q�'q <br /> 0ce <br /> Z 2. <br /> W 4) <br /> 3. <br /> 4. <br /> 14.SpecialHandling-Instructions and Additional Information <br /> hA <br /> ill <br /> 15. GENERATOR'Sl FFEROR'SCERTIFICA71ON: 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 /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfiVenerator)or(b)(if I am a small quantity generator)is true. <br /> "Bignature Month Day Year <br /> Generator's/Offerors Printedrryped Name <br /> _j 16.International ShipmentsImport to U.S. ❑Export from U. Port zof entry/exit: <br /> ElTrans orter signature for ex orts only): Date leavinq U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> W Signature Month Day Year <br /> �2Transporter 1 Printed[Typed Name C, IN. <br /> 0 11 V-5 <br /> Month Day Year <br /> M Tra porter 2 Printed[Typed Name Signature <br /> < <br /> uk r2t <br /> 18.Discrepancy <br /> Type ❑Residue ElPartial Rejection ❑Full Rejection <br /> 18a.Discrepancy Indication Space quantity <br /> Manifest Reference Number. U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> LL Facility's Phone: Month Day Year <br /> UJ '18c.Sig-nature of Alternate Facility(or Generator) <br /> S2 <br /> W .Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recy&ng systems) 4. <br /> LU 1. 2. <br /> 3.C3 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a. <br /> Month Day Year <br /> r <br /> F;.7n-tedrryp.d Name Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />