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i <br /> Please print or type.(Form designed for use on elite(12-pitch)typew.,. Form Approved.OMB 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 C 8,t. OQQZU ® I 1110 2-Z Soo 000268685 JJ <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> G F3' f"Qek-rtr.5 FL�frJ� , eAv�L LAZ4 <br /> 333 u A T L. STS LST' 1$01 N• Jack. ToNt IZ.D <br /> Generator's Phone: 11)7'.7-00 t O r, G4- 4.5.3 6 6 <br /> 6.Transporter 1 Company Name rU.S.EPA ID Number <br /> tJD RnA.S �Ji U S �J C, CA 2 Q 001 g k I <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> i <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> WA5M MA-J4(4€M1-:0 TI , CA_2TOnl <br /> ~¢- -u SK! <br /> c4�e-" . q0-F <br /> Facility's Phone: [ t O) Z/ 7- fQ 3 V O <br /> 9a. 9b.U.S.DOT Desci tion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> ix 1. 1JOPt - Q-C" 44Zd¢J>0,r S WAST~ "O <br /> 5l,r-5 <br /> t- ( F1-g6 "!Ts u9c. g PIPE) I C M 1000 P <br /> r <br /> L z. <br /> � i <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> wtA-2. (n 1.OV E$ $ A-voo 15,16 Com 4 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are ciassltied,packaged, <br /> marked and labeled/placarded,and are In all respects In proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Content. <br /> I certi that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen r)or( 'I am a small quantity generator)is true. <br /> ne oral roes Pri Ryped Name K <br /> ature Month Day Year <br /> (�� S q o <br /> -1 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a A-L, Q S;r t.1 > 2 9 0C� !. <br /> 4 Transporter 2 PdntedlTyped Name Signature Month Day Year <br /> tY <br /> d- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year I t <br /> F- <br /> z I V, <br /> C7 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® i. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature Month Day Year <br /> i` <br /> l <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED); <br />