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Please print or type. 7 <br /> UNIFORM HAZARDOUS 1_Generator ID Number 2 Page 1 of 3.Emergency R Form Approved.OMB No.205OM39 <br /> WASTE MANIFEST C' esponse Plane 4.MwIfI TnackNumber <br /> 5 Generators Name and Mailing Address - 7115 013940031 F L E <br /> or►TOM -r0eA tJJPGaTA?Jlotj or rer-ators Ile Address(if(III than mailing address) <br /> I-S FCeeWAY NoS�T�I BovN P.v G �'` G <br /> j&ll; CA 7,530 9100 §� Sp,f✓i <br /> 5 Transpoder 1 Company Name T — <br /> G U.S.EPA!D Number <br /> 7.Transporle•2 parryNana :rI(, M Q /-� <br /> U.S.EPA ID Mxnber -"/ <br /> A.Desgnaled Facility Name and Site Add2ss <br /> Ctj 14Af-L50Rd 6uT�'oW' /1IU0i J LLC U.S EPA IDNumbe <br /> Z�Soo KNELP*r LO KK C-0,4 F-Ap /� n <br /> Facir s B.Qw'LCoW1CA 93ZO CIAD I p <br /> 30�97SZ��o <br /> �Lf 2—So <br /> 90.. 90.U.S.DOT Description CmGWing Proper Shippirru Name,Hazard Class.ID Number, <br /> HM and Pecking Group(if any)) 10 Coraners 11.Total 12.Unit 13.Waste Cordes <br /> ON— <br /> I /�/ Na Type Quantily wuvd, <br /> KC RAZAX,30VI ►��1sT XOZ/Z! 35 <br /> k1E,Fft Cv►JTilM,NATE9 .� G l CM (c) <br /> LU <br /> 3 <br /> 4 <br /> 14,Special Handling Insbuclians and Additional bsformation <br /> CN IS-l�ll� <br /> .5. GENERAT17R'SlDFFERDRS CFATIFFCATION:I hammy declare Nat the contains of this consignment are fully and a —rely described above the <br /> marked aM Iabaledlpktrarded,and are in all respects in thl Proper slipping name,end are classified,packaged. <br /> P Pmm ooMilbn s Va�pcd axardkg b apprigble�temational and nabonal govemmental reW011 re.If Wood shiomenl and I am Ne Primary <br /> Exporter,I certify that Vie Gunlents of the corsgrment conkum b Ca temp of Ne attached EPAAtlaaw <br /> I certify that the rrasle minimiz statemenl bendlied in 40 CFR 262.27(x)(if I am a large quantityiedgmenr at nal am <br /> Ge neralors101femrs Pdnled/Typed Name generator)or(p)lift am a small quantity generator)s We. <br /> / Signature Monty bay Year <br /> 16.International Shipments s lO <br /> ❑Import to U.S. l J Export from U.S Part of entrylexir <br /> ? Transpoder sgnature(fpr exportsonly)' ---- <br /> O� 17.Tres Date leavug U.S.' <br /> nsPdr>er ArRravAedgment of Recepl d Maleness <br /> aTransporter 1 Pnnlcd/Tyoed Name <br /> CL SgraWre Month Day Year <br /> z I YC <br /> Trenspodnted <br /> er ri /Tnad Name Sgnalure <br /> Monts Day Year <br /> } <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Cl QuantityType 13 Residue ❑Partial Resection LJ Full Rejecfim <br /> 18b.Allemale Faalily(or Gerzranr) Ma+ifesl Reference Number <br /> —x U.S.EPA ID Number <br /> U <br /> LL Fad tys Plane: <br /> F18c.Signature of A1lemate F—uy(or C�enerazor) <br /> Month Day year <br /> 19.Hazardous Waste Repoli Ma <br /> LU apo nagement Me"Codes(i.e.,codes for hazardous wase treatment.disposal,0.M recycling systems) <br /> 1 <br /> H)I'L <br /> 20.Designated Facility Omer or Operalor Cedification of recaipi of hazardous materials covered by the Day Year manifest except as noted in Jim 18a <br /> Prinied/Typed Name—Te <br /> Monty <br /> � v e,r � D <br /> EPA Form 8700.22(Rev.12-17)Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />