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CY) <br /> C0 <br /> co N <br /> L _ <br /> Lf) O <br /> O N <br /> ry- <br /> __.,x�I Nea\th DePartmeM <br /> it <br /> O <br /> U <br /> Please prim or ty>e(Form des raid for use M stile 12 Itch)I wnt- Fnrtn proved.OMB No.20560038 <br /> UNIFORM HAZARDOUS 1 fieiloraNr ID Number 2,n,xln 7 0l l F.mnrt3enry RmPeniw Prprw "614053016 <br /> M Oeq cklrlp Num <br /> WASyTE�MNAaNnI�FE�ST G A l.00 3 4 1 1 7 9 I 111 4'4B3f10 X11 0 5 3 016 JJK <br /> 5 Goner eat til k RFl 9'H'19P 'f I ER om e.tre.site Addreae 01 dillerrml Than maxien-um- <br /> 3333 S HMlT 99 <br /> �TiN:kii riJ i.A s�t;t:i'i HWHWAY'd`e <br /> ?Ota�x7 t r rkK, 'l I04A,JON al <br /> Gm�emlw's Phone' <br /> 6,TronsPmler 1.CATH ?NgWrNMl hi S1 RVI-i US,EPA ID NUmprr <br /> A-`iHUlfl-[IYV .A:1 O'2 A- r 7 0^. <br /> Trens{Vq�dpeQr�2 Company Nya`m`tlo �9 qd q p U.5.EPA ID Number <br /> ,9 Designated FaSIN WAT[RSITPUMOLCIGIF 91 I•, US.EPA ID Number <br /> 533751k)UTM 80YLE AVENUF <br /> LUSANGk LES GA f;AUra,I <br /> P-htys Ph— 1323kT7150D <br /> oa 9b.U.S.DOT Description(Induding Pmper Shipping Name.Huard Class,ID Number. 1n.Containers t I.Total t2.Unit 13.waste Codas <br /> HM and Packing Group(if s y)) W 'rype Oua,my wI NO <br /> p <br /> a <br /> w <br /> z <br /> w <br /> 0 <br /> T <br /> U <br /> 4 <br /> C <br /> O <br /> 14,Special Handling instructions and Additional Inrormabon <br /> EMERGENCY CONTACT CHEM110 a.4 J:31/U WAlxari.�u.1 <br /> N <br /> -0 ' 1MRTICUTA'fES` "APPROPRIAI 't PttAIE'CTIVE EQLIIPMENI <br /> 0 15. GENERATOR'SIOFFEROR'SCERTIFICATION:I hereby declare that the contents of Nis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacamled,and are In all respects in proper condition(or transport according to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> T Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cisrh y that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(bl(if I am a small quantity generator)Is true. nlonlh Day year <br /> T <br /> GeneratoesrOfferor's Printed/Typed Name Signature <br /> Q <br /> 0 16.1 hurnationat Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> f Date leaving U.S.. <br /> Transporter signature(for exports only). <br /> O 17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> - w Signature <br /> Q) w Transporter 1 PrintedFryped Name` - <br /> _ a - �,e/ <br /> -� z Transporter 2 Printedflyped Name v <br /> Signature Month Day Year <br /> Q <br /> 0) <br /> 18.Discrepancy <br /> rn ❑Residue ElPartial Rejection ❑Full Rejection <br /> 918a.Discrepancy Indication Space [I Quantity lJ Tvfe <br /> Y Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator, <br /> � J <br /> O u <br /> r0 LL Facility's Phone: Month Day Year <br /> Ci <br /> LO <br /> 181.Signature of Altemate Facility(or Generator) <br /> CD Q <br /> O O = <br /> C N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> d') O o 1 2, 3. <br /> Q � <br /> U I <br /> 20.Designated Facility Owner or Operator:CeAifiralion of receipt of hazaMous materials covered by the manifest except as noted in Item 183 Month Day Year <br /> O O Ptinled/Typed Name Signature <br /> O O <br /> O <br /> GENERATOR'S INITIAL COPY <br /> m 8700.22(Rev.3-05)Previous editions are obsolete. <br /> O U) <br /> - U) <br /> U 2 <br /> Z) N LL1 <br /> CY) <br /> C = T � <br /> U00 0 <br /> � CZ <br /> cy) NO U <br /> C'') N = <br /> � CY) ra <br />