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'4 011 11�ii L. F. W. MFG. I NC. FAX N0. : 209 465 6521 Mar. 15 2007 11: 26AM P2 <br />Please print or type. (Form designed for use On elite (12 -pitch) typewriter <br />BPA Form 8700.22 (Rev. V15) Previous editions are obsolet®. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />I. neratOr It] Number Porto Approved. OMB No. 20$0-0039 <br />tJNiFORM HAZARDOUS 2. Page le 3. ErTrar �f gsryo�p�phone 4. Manifest Tracking NrrmD®t <br />WASTE MANIFEST P d SFS Q <br />5. Generators Name 0 0 2 5 8 3 9 5 4 j4 <br />and Nlafiing Addre s / i , J� , R el Generator`s Site Address (if different than mailing address) <br />07� <br />Generat6r's�ho� <br />b. Transport 1 Company Na <br />Yeigr+cQn 96ircanmefbi9 Spices U.S I <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address EyE groan , iflC U.S. EPA ID Number <br />510-7M-44M5midh Ave. <br />4N 1irk. Ca. CAL i�s'418 <br />Fdcfl" s Phone: � <br />9a, 9b.11,$, DOT Description (including Proper Snipping Name, Hazard Class, ID Number, 10Containers <br />HM and Packing Group (f any)) , 11. Total 12. Unit <br />_ 13. Waste Codes <br />No. Type Quantity Wt.Nol. <br />2, <br />L_ <br />Z <br />LLI <br />2. <br />3. <br />a, <br />14. Special Handling Instructions and Additional Information <br />'ear Proteebw EquaUMET'j, ERGE /% r <br />Invoice# Sales Grd <br />Z!!!�! <br />15. GENEKATOR'WOFFEROR'S CERTIp1CATtON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassifiad, packaged, <br />marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national gommmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the Wntents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 28227(a) (if I am a large quantity generator if t am a small quantity generator) is true. <br />Cone erors Pn, ... yped Name Signatu Month Day Year <br />V&%AJ <br />LULA_�� <br />dM"a— <br />18. International $hlpmerft 1 3 <br />_...... Elmpod to U.S. ❑ Export from U.S. Port ofentrytexlt <br />J <br />Transporter s�nature (for exports only): Date leaving U'S.; <br />12 <br />17. mansporwrAdOnowf_e0ment of Receipt of Materials <br />11 "go <br />spotter 1 P i Name . S natu>B y <br />ear <br />< <br />T 2 Prin erne ature Day Yaw <br />g <br />r� <br />18. Dlsaepancy <br />18a, D ocrapancy indleatfon Space © Quantity ❑ Type ❑ Residue ® Partial Rejection ❑Full <br />Rejedfon <br />Manifest Reference Number. <br />18b, Alternate Facility (or Generator) <br />U.S. EPA ED Number <br />c� <br />Facilitys Phone; <br />® <br />d <br />18e. Signature of AiremTte Fadlity (or Generator) Mpn pay Year <br />Z <br />19, M*ardous Waste Report Management Method Codes (I.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />a <br />1. 2. 3, 4. <br />20. Designated Facility Owner or operator; Certification of receipt of hazardous matefWs covered by the manifest except as noted in Item 18e <br />Prfnted yl 3@ dName Signature anti Day Year <br />i ! P <br />BPA Form 8700.22 (Rev. V15) Previous editions are obsolet®. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />