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Please print or type.(Form designed for use on elite(12-pitch}typewriter.) r Farm Approved.OMB No.2050.0039 <br /> NIFO flt HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.1115 t 1'rackin�QNumber �{ �} <br /> WA5T1=IYIANIFEST r 1 7 V � .nJ J 4 1 4 f F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 17 LftAo <br /> wed Scha l Dill lri;! {Sierra 14*) <br /> Eiiar4w.a, CA 96337 <br /> Generat0e5 Phone: " ) <br /> 6. ransporter 1 Qompany Name U.S.EPA ID Number <br /> AdArl[SBd DmIxTs 3l Tra-ii hric. (SV) CAR0001l <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Dbsomilied'Facility Name and Site Address U.5.EPA ID Number <br /> M' M F F4.11 1 S Baty <br /> '9901f3 M�'3.300 i OOL�Q <br /> Facility's Phone: 776-%34=3 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt..Nol. <br /> a NA3WZ Hazardous waste,kgtdd,tl o.s. (Photo Sihrc'!r 7Q1 <br /> ? 2. <br /> ur <br /> (7 <br /> 3, <br /> 4, <br /> 14.Special Handling Instructions and Additional Information Ill NAn*W 145412 010curtrll" D174W6 <br /> 1)61"171; 07 013775111 Willil,00 1 <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:-I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are ir.all respects in-proper condition for transport according to applicable international and national governmental reguiations.ff export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cArdorm to the terms of the attached EPA A.dtnowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Geneirabbir'sl0fiferces PrintsOyped <br /> 1 me <br /> re ayeaearr <br /> i++ ( it <br /> ! <br /> j 16.International Shipments El� Importt to U.S. ❑Export from U.S. Port of entrylezit: <br /> Z Transporter signature for exports only): Date leavin U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T er P' drypedName gin re <br /> 11W 41 le- vi q o�,a-z, <br /> 17 1 <br /> fZQ nsporter2 Printed/ryped Name signature mormay esr <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indicator.Space ❑ Quantity ❑Type ❑Residue ❑Par3lal Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 181b.Alternate Fealty(or Generator) U.S.EPA ID Number <br /> J <br /> Fadl' 's Phone: <br /> F18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> • '. � �+� 2 3 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Jam!"a—, <br /> PrintedfTyped Name Signature Month D Year <br /> EPA form 8700-22(Rev. -05) Previous editionlare obsolete. J DESIGNATED FACILITY TO GENERATOR <br />