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Please print or type.(Farm designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nunlber2.Page 1 of 3.Emergency Response Phone I Manifest Traciting Number <br /> WASTE MANIFEST C'"'102""' "-24-1131"') <br /> 2 4—1130 015970997 J J K <br /> 5 Generator's Name and Mailing Address Generatoes Site Address(if different than maifmg address) <br /> -,tubo Fart! — 2041 !tory Dz <br /> o>a, CA Moi <br /> Generators Phone: 530 310-5179 <br /> 6 Transporter 1 Company Name U.S.EPA tD Number <br /> 1d* V ay.t...s -e000175422 <br /> 7 Transporter 2 Company Name U S.EPA ID Number <br /> 5 Desgrated FaG�tgiajr== TJrlk'rU.S.EPA ID Number <br /> R. tlfizat s�t- <br /> CA 92702 <br /> Facility s phone: 626-334-5227 cj"083ol on3 <br /> ga 9b U.S.DOT Desi(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Typo Quantity WtNol. <br /> 10 Elk <br /> 11(7 � <br /> W <br /> W 2 <br /> 0 <br /> 3 <br /> 4 <br /> 14 1�pec!a!Handlin Instructions and Addhional Information i <br /> LQ Bold VMX Iftap& Pft Clothing + --.So of Slnil&tgeftry CM0t&CtCRUlli <br /> ��Qn! <br /> 300 PAM#4txalnt 1CM111174731* - 5!1 <br /> 15. GENERATOR'SIOFFEROA'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 labeledlplacmded,and are in all respects in proper condition for transport according to applicable intemabonaland nadianal governmental regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(41 am a large quantity generator)or(b)(if I am a small quantity generatcr)is true. <br /> GeneratorsiMnor's Printedfryped Name Signature Month Day Year <br /> .j 16.intemanonal Shipments <br /> 1:1i— Import m U.S. ❑Export from U.S. Port of entrylaxit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P6nted(Fyped Name Signature Month Day Year <br /> ) - <br /> OA ``l) ' <br /> Q Tran porter 2 PrintedfTyped Name Signature Month Day Year <br /> a (7 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 0uarrtity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 16h �Qrmate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rar- Faetity's Phone <br /> Lu 1 Bc.Sign alure of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> n19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardeis waste treatment,disposal,and na yyding systems) <br /> Z 1. 2. 3. 4. <br /> 20 Designated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in 18a <br /> Phnted7yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-0 ) Previouaelfrtiansare obsolete, DESIGNATED FACILITY TO GENERATOR <br />