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9K 1' I:t f:rsit;3S ls+ <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST :[?r)c)HPIZi r 3r <br /> ($ SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing seeress) <br /> 11-: <br /> Generator's Phone rad <br /> 6,Transporter 1.Company Nam :i!-E!+'i5 INC U.S.EPA ID Number <br /> .., ." 1'X�tfli4lr(I#OE)lc'i!t'; <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address mS'AFF TY--! LEV:.N OF ��AL.I FORK I A U.S.EPA 10 Number <br /> NEWARK CA 94760 <br /> t-51111-795-4400 GAL19A0887416 <br /> Facility's Phone: <br /> ga gb.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)) No. Type Quantity Wi.Nol, 3.Waste Codes <br /> 1'NON—RCRA HAZARDOUS WIASTI g I_Iouiii Ti G P21 <br /> o (USED 01L) <br /> p <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information "I5I)1 F V61 74bL0234 CA47954r G. <br /> Hk EMERGENCY Niki--80lti-41e-8-1760 413K t i-F I) <br /> -s _rr ,i __-jl Y' 4Y Tfl ars:'}r hJ )C'' i='rl i K f^r) rr:s h'rgC <br /> 15, GENERATOR'S10FFEROR'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 labelediplacarded,and are in ail respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter, certify fiat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> cerli€y that the este minimization statement identified in 40 CFR 2 2.27(a)(if I am a large quantity generator)or(b)(if I am mall quantity generator)is true. 41 <br /> Generator'siOHerpr rintedrTyped Name Signature f/./I Month Day Year <br /> L! <br /> ri 16.InternationahShi fit <br /> F ` . ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only), Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Mater als <br /> LLI <br /> Transporter 1,Printedrryped Name Signature Month Day Year <br /> Ln <br /> ��.., <br /> Q Transporter 2 Prinledriyped Name Signature Month Day Year <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> 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 r." <br /> Facipty's Phone, <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 0 1. 2. 3. 4. <br /> 20,Designated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as need in Item 18a <br /> PrintedlTyped Name Signature Month Day Yegf <br /> EPA Form 8700-22(Ree 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />