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o a Form Approved.OMB No.2050-0039
<br /> 9 0 onn designed for use on elite 12-pitch)typewriter.) 14.Manifest Trackin Number1.Generator ID uer ,>; =7 y 2.Page 1 of 3.Emergeny.tlse Ph9 ,i M a:
<br /> A7ARDOUS �.;�� Cy�.l�i u'l� �)�s � � � J
<br /> a N MANIFEST y� a T' . ,wB
<br /> ra1Pt's N e akin pd{resg Generator's Site Address('kf different than mailing address)
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<br /> ;3�-7'r {yEt[F 1:YtiTOTIr t_.lht 95232
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<br /> Generators Phone: U.S.EPA ID Number
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<br /> U.S.EPA ID Number
<br /> 7.Transporter 2 Company Name t (
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<br /> U.S.EPA ID Number
<br /> 8.D sign ted.F�g�lity.tameand Site Address
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<br /> Facility s Phone:
<br /> 9a 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Wzfite Codes
<br /> HM and Packing Group(if any)) ;•' No. Type Quantity WLNoi.
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<br /> 14.Special Handling Instructions and Additional Information
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<br /> 15. GENERATOR'SIOFFEROR'S 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 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 EPA Acknowledgment 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)(if I am a smM.quantity generator)is true. Month Day Year
<br /> �16.
<br /> nerator's/Offgror'sPr)nted/T d��Nyyame Signature
<br /> Port of entry/exit
<br /> l International Shipments Ex ort from U.S.F,,,, ❑Import to U.S. P
<br /> Z Transporter signature(for exports only): Date leaving U.S.:
<br /> IX 17.Transporter Acknowledgment of Receipt of Materials Signet A `'` `^. Month Day Year
<br /> F-• Trans orter 1 Printed/Typed Name g,''�y 4g p .P / /J p
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<br /> Z Transporter 2 Pdntedrryped Name } Signs,)u, tyjq v a
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space El Quantity ❑Type .r ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number:
<br /> '�tF OFFSITE U.S.EPA ID Number
<br /> 18b.Alternate Facility(or'Getreraton)!'-EA' -!E.n '-'R REUSE.CROSBY 12 OVERTON,INC OPERATES TTIE FACUM UNDER
<br /> J ..atlYiGlt,;;"!',:i)'S0'?1'.i'..BY T.M..DEPAHIMENN OFTOXICSUVSTANCE(X)NTROI.TOCETIF-R
<br /> 0 Tii'3 i$•E�'IFO0.'S.'�V.'.::..PFOT2010t'AG5NCY LN ACCORJ�ANCE WIT11 THE PROVISIONS OF
<br /> Q i'3i= X,'-.7:;UR. E y:G:J_i 1�ATTON NrD i•:%ra�'��45 ACT OF 076"rDGFTlil7t W
<br /> L. Facility's Phone: _ Month Day Year
<br /> 16C.Si nature ofAltemmaa��e Ea t r E�P� "''' 071,737 s Q YON HAS ALI. OF THE NECESSARY
<br /> F 9 7'�rc�,da l �RF.E'FRkNChD WASTE AND ALL THE WASTE HAS BEEN HANDLED
<br /> Q ACCORDINGLY
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifes rept as notedT Item 1 Be
<br /> Si na re-,• t,
<br /> Month Day Year
<br /> PrijEtedl_7ed Name r1. 9r
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - DESIGNATED FACILITY TO GENERATOR
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