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FROM : L.F.W. MFG. INC. FAX NO. : 209 465 6521 <br />Pease Ddnt or tvoe. (Form dosionecf for use on elite 112.nitchl tvnewrttor ) <br />Mar. 09 2007 09:39AM P7 <br />EPA Form 8700-22 (Rev. 33-055) Pwhous editions are obsolete, <br />DESIGNATED FACti.lTY"rp GENERATOR <br />UNIFORM HAZARDOUS 1 GVnerator ID Number <br />WASTE.MANIFES7 r s <br />' �^ <br />2. Page I of <br />3, Emergency Response Phone 4. Manifest Tiracking Number <br />:. i r ., �� ✓j�� <br />p <br />3 3 JJ <br />5. Generator's Name and Mailing Address Generators Site Address (If different than mailing address) <br />•. G� �,.' �✓l <br />Ger,erraior's'Phone: . <br />6, Transporter I Company Name U.S, EPA ID Number <br />T. Transporter 2 Company Name U,S, EPA ID Number <br />regale " riEgif <br />8. FacSity Name and SkeAddress Y U.S,. EPA lit Number <br />2- I ,it cenl~wy� I <br />"'� iRS�a�e3:�ras$r T}u2aara, i�a-Gv� <br />Fad' 's Phone: <br />ge- <br />HM <br />9b. U.S. DOT Deschption (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (d any)) <br />10, Conminers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />rijpe <br />quantity <br />Wt Noi, <br />W <br />2. <br />w <br />8. <br />4. <br /><q <br />14. Special S lftttruclions and AdditionalInformation <br />w. —1e <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 nama, and are classified, packaged, <br />marked and labeledlplacarded, and are In all respects in proper tondition for transport according to applicable international and nxaonal governmental regulations. if export shipment and I am the Pdmafy <br />Exporter, I candy that the contents of this consignment conform to the terns of the attached EPAAcknotvledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if 1 am a large quantity gCnerator) or (b) (KI a small qusnd generator) Is true. <br />GeneratoNOtferoes PrintadffyogilWame f Signature Math Day Year <br />...r <br />� <br />16. Inter»stlonal St*ncrts <br />import to U.S. ❑ EXpofl tram U.S, Port of entry/exit: <br />Transporter riignature (for exports only): Date leaving U.S,: <br />uj <br />17. Transporter AdmowlAment of Receipt of Materials <br />Tkanggprtrtr 1 Print Name Signature Marsh Day Year <br />to <br />T Print ped Name Si J Month Day Year <br />18, Discrepancy <br />18a. Discrepancy Indication Space Ll quantity ❑ Type ❑ Residue ❑ Partial Rejection © Full ReJection <br />Manifest Reference Number: <br />F <br />18b, Akemate Facility (or Generator) U.S. EPA ID Numwr <br />V <br />Fact{ty's Phone: <br />w <br />18C. Sic atuee of Ahcmete adety for Generator) <br />Month Day Year <br />y18. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />1, <br />2. 3. <br />4. <br />20. Designated Fa(Alty OWnCr Cr Operator: CerGGCaton of Ibcwipt of hatarduua rnaledm1b wvered try tw rndaikrlat r, Pl as ttrted In Item '16a <br />lr t ped Namei 5 1 4 tv I� % i j 't Month Day Year <br />d ^� r; 11 ✓ t b. f � ' , s <br />EPA Form 8700-22 (Rev. 33-055) Pwhous editions are obsolete, <br />DESIGNATED FACti.lTY"rp GENERATOR <br />