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Please-print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No.2050-0039
<br /> :UNIFORM HAZARDOUS i Generator IDNumber . 2 Pageto 3, Emergency Response Phone 4 Manifest Tracking N ber .WASTE C,CJ to� 4ay ft' ,. S�-Ga. .a pz k z_ r`; '.,_
<br /> TS 4 J Ez S ®® C yr DAT
<br /> ( '= 5. Generators Name and Mailing Address !"TTt�. / , t,=i1 ; I T iT- "Generators Site Address (if different than mailing address)
<br /> rifr; t.tr � C1 sate TUSD - Tne F c r4 a:
<br /> Te c', CA, TMD ^, CA95376
<br /> - Generators Phone: '2WT�A:t?i 434
<br /> 6. Transporter 1 Company Name U.S. EPA 10 Number
<br /> C v .y, f117:1747
<br /> 7. Transporter 2 Company Name U.S. EPA ID Number - - - -
<br /> clwn Privrc .; EPt t r€ 4., kck INW39S22250
<br /> Si De ignmed Facility Nam and Site Address _ _ . , ,__ _ _... .. _: . - . - ". . " _ _- - -_U.S_EPAID NumbeL
<br /> 8Z Hamm SSt Jrasr@, LLC
<br /> 1021 aa. Rosd
<br /> sa1T Jae, CAP51n
<br /> FadItys Phone: 4': h44 1 4CAU
<br /> ga 9b. U.S. DOT Descriplion (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit
<br /> HM and Packing Group (ff any)) - No type Quoddy Wt.NoL 13. Waste Codes -
<br /> t�.E1ii�- 033 2 D33S (,iti1
<br /> o r c IG DoT rrw1
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<br /> w 2' Er. ? 7i f tis t ^f aa1f , F .c 5 . (. Ifs , €t Dox Doi 1 F€M78
<br /> 1 a �` 352
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<br /> 14. Special Handling Instructions and Additional Information D73u"F,l SO `122814
<br /> 1 ) CH81E279 2 ) CHS51Et2
<br /> tJ Iir6, ce trt,Tm , try3jra,i;}gc um4, x c .66n op r c o t 1„uf ! t*r<,ipxlIto aha r_ E. x: rtc c.K6xi � m,M ,t r rr„ .c
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,
<br /> marked and labeledlplacarded, and are in all respects.in proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Primary
<br /> Exporter, Icerlify (hat the contents of this consignment conform to the terms of the attached EPAAcknoivledgment of Consent. I - -
<br /> I sandy that the waste minimization statement identified in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (if l am a small quantity generator) istrue..
<br /> Gen IorslOfferorss, Prated/ yped Name - Signature // - 'Month Day : Year.
<br /> 4� /': f - r/ r l / t �. 1 ( J .
<br /> % /rte
<br /> �A 16. international Shipments -
<br /> t- .. - ❑ Impart to U.S. ❑ Export from U.S. -Port of enti
<br /> z Transporter signature (for exports only): - - - Date leaving U.S.:
<br /> w 17:1firanspoderAcknowiedgmenl of Receipt of Materials - - -
<br /> Transporter 1 Prin(ed7fyped Name _ Signature �--> Month Day Year
<br /> 4 Transporter Pdrsed/Typed Name' Slq�anure'--a"�.:+” ,�---^ �_ .�1._.� Month Day Year
<br /> 14lFf rr G ( L, I.v A ,a! b /, "T tG1/ / _
<br /> 18. biscrepanc`e _. r a • r : r -a=x.� —' .. -
<br /> 18a Discrepancy Indication Space ❑ Quantity El Type
<br /> ❑ Residue ❑ Partial Rejection El Ed Rejection
<br /> Mandell Reference Number:
<br /> r 18b. Altemate Facility (or Generator) U.S. EPA ID Number _
<br /> J
<br /> LL Facilltys Phone: - -
<br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year
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<br /> 19. Hazardous Waste Report Management Method Codes 0 a., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> � . 20. Designated Facility Owner OrOperto Codification of receipt oDazardousmterials covered by the manifest excep6as noted hr,llem 6/' ,
<br /> Printed/TypedName / Signalure� F�� / / Month Day . Year -y
<br /> // iL
<br /> _
<br /> EPA Form 8700-22 (Rev. 3-05) Previouseditions areobsolete. Jj : /`,-. ,,_ �/ DESIiGWATED FACILITY TOGRERATOR
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