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l <br /> Please print or type. Form designed for use on elite 12- I(ch)t pewriter. Form Approved.OMB .� <br /> UNIFORM HAZARDOUS I.GeneratorlD Number 2.Page 1 of 11.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST 02• 445714•2Cz?2 4 JJ ; <br /> 5.GeneratE!orsi�CJRName and Melling Address 'Generators SHe Address(II different than mailing address) <br /> b710,A . <br /> P.0.Box � !120 0HAATVF W,A <br /> 4ST01:iKTON,CA 9000r"1 Cr', <br /> Generators Phone:. 94 4V1 4�J2r <br /> 6,Transporter l Coinpeoy Norrie' ' • t i'".'.:• . U.S:EPA ID Number <br /> - <br /> �T.7�L'f1i1;'t71rJ <br /> 7,Transporter 2 Company Name U.S.EPA.ID Number <br /> 8.DeAWOM " " U.S.EPA ID Number <br /> Fadltq?sP.hona;r p �' �i'n('.,aitr :i!':_. ., 'Irs,+ r;^•i:"':.,'i''. lu`ii '.!•'; <br /> 9a.. .8b,U'3 DOT Uesaip8o1((nciudirig Proper Sh('ptng Neme,.yazard Class„Ip Number,..;.;. 10:Coniairiers:... ,:,. ..;11 Total 12:.Un11 . <br /> 13 Waste Codes <br /> HM <br /> :and Packing Group(Itany)) No. 'type Quantity WWoI. <br /> W i{ L itION VIPia'°!'LAV%ptx='WATTO'St3)it3''f <br /> Ir <br /> ?•,2, , <br /> LU <br /> 3. <br /> 4: <br /> 14.Spsdai Handling Instructions and Additional Information <br /> 'RG#171 !h!l'Qit”. t +'f3r7t f!.E,tx <br /> V•vCAf(0Ls,11!E <br /> airs �os� 67""T <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this.consignmenl ate fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledrpiacarded,and are in ail respects in proper condition for tradsport according to applicable intema8onal 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 EPAAcknowledgmentof Consent. <br /> I ceNly that the waste minimization statement Identified in 40 CFR 262,27(a)(A I am a large quantity generator)or(b)jdl am a small quantity generator)is true, <br /> Generalo �O`lt9ror T ntedr typed,Name Signature" Month Day Year <br /> —r 16.International Shipments <br /> ❑ - <br /> import to U.S.U.S, xpoH from U.S.:"'f Port of entry/axil: <br /> Transporter signature(for exports onty):` Dale leaving U.S.; <br /> 17.Transpoderklihowledgment of Receipt of Materials <br /> Transpbrterl ypedNae' Signature �' r Month Day Year <br /> Transporter 2 PdntednWed Name Signature Month Day Year <br /> 10.'Discrepancy" <br /> 18a.Discrepancy Indk allon Space ''' ''Quantity ❑Type ❑Residua 1...-.I Pardal ttajecuon Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> C1 <br /> Faciltys Phone: <br /> 18c•Signature of tamale Fadlity(or Generator) "' Month Day Year <br /> 19,Hazardous WastReport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> uJ 1. 2, 3. 4. <br /> 20.Designated Facility Owner or 0 arplor.CerVilcatbn of recolpt of hazardous,plaledals covered by the manifest except as noted In I Mtge <br /> Pdnted/ryped Namesignature c rMonth- Day, <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. TRANSPORTER'S COPY <br /> i <br /> I <br />