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rn <br /> C0 <br /> co N <br /> ILO _ <br /> � O <br /> O <br /> ry- �( r <br /> a) <br /> Potrero I`f',Ills l I1ndNll � <br /> 3675 Po rero H�yy Lene __ - - - <br /> O <br /> U <br /> mase Crim or IYPr'(Form des'ned for use on ellle(12-pilrh)rypnwriler I Form AGpmved.OMB No.2050A039 i a V—M'aR <br /> I Ge.......DNumbnr ,1'.,�Inl"I n Hr. - al lrecklne NYmtNr JJK <br /> UNIFORM MAJARDOUS :I E.n..r em v tkele�nnne,. 4.M.nVe ,�; y <br /> WASTE MANIFEST <br /> 19f xoB <br /> '-•- anry sx� <br /> �.,nnr u.'.N.nn,.,ria alailin.I An,lrexti ,.,e•.nn„�..I„hlde• el a I,,.,,I ei.u,malling edArencl <br /> —:ol IfU <br /> T wnrry, <br /> Pio <br /> ,,I, „I, „,,npnry Nime US EPA IU Number <br /> - ,oi l-„ .i.,n,pnny Narne U.S.EPA ID Number <br /> rI,.Il a lily Wnle and Silo Address U.S EPA In Number I el <br /> facday's Pnone: - ' <br /> 9bU.S.DOT DescnpUon pnc'ludln9 Proper Slipprig Name.Hazard Class,ID Number. 1G.ConUmers It Total 12 Unn <br /> HA1 and Packing Group til;In,�il No. Type Quantity <br /> I <br /> O , <br /> a <br /> = 2. <br /> T <br /> 3. s <br /> 4. I <br /> O +` <br /> (Z 14.Special Handling Instructions and Additional Information <br /> N / <br /> 0 <br /> 0 15, GENERATOR'SrOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are class'Ified,packaged. .i <br /> lall respects in pmper condition for transport according to applicable intematlonal and national governmental regulations.If export shipment and am the Primary <br /> marked and abeled/placarded,and are in <br /> T !) Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> > I oedity that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or @I(if I am a small quantity generator)is Ime. Month Day Year <br /> T GeneratorsJorandes PnntedlTyped Name <br /> Signature <br /> Q- <br /> 0 <br /> O0 J 16.International Shipments El Import to U.S. Export from U.S. Port of entrylexiC <br /> 1— Date leaving U.S.: <br /> = Transporter signature(for exports only): <br /> O 0C17.Transpo twAcknowledgment of Receipt of Materials Month Day Year <br /> -0 w Signature <br /> Q) C Transporter 1 Printedlfyped Name <br /> O <br /> Q- Monln Day Year <br /> Transporter 2 Printed/Typed Name Signature <br /> -in a <br /> 0 <br /> 18,Discrepancy <br /> �1 ❑ ❑ ❑Full Rejection <br /> y i 18a.Discrepancy Indication Space El Quantity Twe Residue Partial Rejection <br /> Y ' f Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 186.Alternate Facility(or Generator) <br /> � J <br /> (D U <br /> 'Cf LL Facility's Phone: Monet Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> LO <br /> LO O <br /> _ z <br /> O <br /> CV In H 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) y <br /> 0') C:) <br /> O i. 2. 3. <br /> Q � <br /> U C 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifesl except as noted in Item 18a Month Day Year <br /> C <br /> C Printedrryped Name Slgnalure <br /> O <br /> EPA Form 8700-22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> a, O 2 <br /> Urn 2 <br /> LLI <br /> N C/) N O 0 <br /> � CZ <br /> CY) N0 U <br /> ('•) N = <br /> � cy) r � <br />