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E <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />C <br />Eim <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />4 . , ,)�j..a ',+C,-. <br />.`tt3�s{000982264 <br />L <br />5. Generator's Name and Ma)rla9 Address a "� y qk Generator's Site Address (if different than mailing address) <br />r � <br />Generator's Phone;.' <br />hone <br />ransporter 1 Company Name U.S. EPA ID Number <br />%1 iPtA R ,A "SAL LL Y W A 41 L 01#,. CA 00062 N t <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. U.S. EPA ID Number <br />5300CLAOS ROA0 1011)01.901 4 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Noi. <br />1. Nc"34440,>$A tdA/,ROCIUS; WtN,STV t lQUIt D <br />12 i <br />s <br />ItJlSf-i.1ast1 YWAIi'1� 1 <br />0 €3 '1 <br />T :f <br />G <br />Z <br />2. <br />Uj <br />j <br />i <br />3. <br />I <br />4. <br />k <br />°7 <br />t4 Special Handling Instructions and Additional Information <br />13L0VF. <br />15. GENERATOR'SfOFFEROR'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/piararded, 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 terns 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 small quantity generator) is We. a' <br />eneratcest eror's Printed/Typed Name Signature on ay Tear <br />J <br />ll <br />16. international Shipments <br />❑ Import to U.S. ❑Export from U.S. Port of entry/exit: <br />s <br />Transporter si nature for exports only): Date leaving U.S.: <br />w17. <br />Transporter Acknowledgment of Receipt of Materials <br />Transported Printed/Typed Name Signature Month Day Year <br />a <br />f / <br />Z <br />Transporter 2 Printedfryped Name Signature month Uay Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space 171 Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />W <br />Facility's Phone: <br />W <br />18c. Signature ofAttemate Facility (or Generator) Month Day Year <br />Q <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. 2. 3. <br />Notice: New federal form. State of <br />California requires generator to photocopy <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a 9 P PY <br />Pdnted/Typed Name Signature and mail to DTSC within 30 days: <br />P.O. lox 400, Sacramento,CA 95812-0400 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />