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Please print or type, (Form designed for use on elite (12-pitc writer.), Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS I. Generator ID Number 2. Page 4 of, 3. Emergency Response Phone 4. Manifest TracId Nu ber <br />WASTE MANIFEST <br />,0 s W <br />O 004S 707 JJK <br />5. Generators.Name and Mailing Address Generator's Site Address (if different than mailing address) <br />a T ;A.II;-4414d1I 'i"4z` <br />I M3 �0, 15 n ! <br />STOCI <br />4710N. CA 95322d_; <br />Generator's Phone:•s <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated -Facility Nameand Site Address - - L. U.S. EPA ID Number <br />Facility's Phone: 5-10" 795-44M <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any)) 13. Waste Codes - <br />g No. Type Quantity Wtivol. t <br />Pf�.�d <br />LU <br />0 <br />3. <br />4. <br />14. Special H dling -instructions and Additional Information <br />tt7 57 <br />17 1M <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION.: 1 hereby declare that the contents of this consignment are fully and accurately described above by the propenshipping name, and are classified; packaged, <br />marked and labeled/placarded, and are ip all respects in proper condition "for transport according to applicable international and national governmental re dfations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment co form to the terms of the attached EPAAcknowledgment of Consent. <br />6 f 51ll <br />1 certify that the waste minimization stateme t identified 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I aS squantityenerato` r) is die. <br />Generato PeRA is Print d/Typed Name` Signature Month D Ye <br />--r. 16. International Shi ments r <br />p ElImport to U.S. Export from U.S. Port of entry/ t: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LM 17. TransporterAcknowledgment of Receipt of Materials <br />Transporter 1 �Pniped Namg Signatures :' Month D Ye <br />d >' <br />4 <br />71 <br />2ETransporter 2 Printed/Typed Name ___ , Signature Month DayYear <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type : ❑ Residue ❑Partial Rejection <br />Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />..a <br />:Facility's Phone: <br />uj 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />19. Hazardous Waste ReportManagement Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />®: 1. LAJ <br />g f 2 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signatur Month` Day Year ' <br />t <br />J Oct <br />EPA Form 8700-22 (Rev. 3-05) Previous ed#tions are obsolete. DESIGNATED FACILITY TO GENERATOR � <br />