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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 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phoneanifest Tracking Number <br /> CAC <br /> WASTE MANIFEST UY1,621.4", r0021822428 JJK_ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> RM�4,Sh + pwuti'514t;KL <br /> VY! V_olfit),­,'hi�44;Cw+�414N(1-4 1) 1 17f 1019& I'Vit <br /> CA <br /> Generator's Phone: R I -A I > if hi <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter2'Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Chenw,o)Mi"A.! <br /> M�l <br /> N(Ad_0111e,Vjul< 4J <br /> Kdtk,mmi Cit-,,(`A a Yak I I <br /> Facility's Phone: <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)) No. Type Quantity Wt.Nol. <br /> RC), 1-:t k,4 fill o"AlhAv lia--urd(mc, <br /> f8t)J with 1,4440 <br /> Z Z. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> fljf,fift; 4.Aijt il"P,IV)et4 i [+,?i, <br /> weof flycfpc'l 1,111E w1w,11 flffl.Ahllt�moic',lia; <br /> 15. GENERATOR!SIOFFERORIS 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 labeled/placarded,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,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 /> Generatoes/Offeroes Printedrryped Name Signature Month Day Year <br /> =j 16.International Shipments ---MExport from U.S. Pon of entry/exit: <br /> 16— 1:1 Import to U.S. <br /> LE Transporter signature(for exports only): Date leaving U.S.: <br /> LW17.TransporterAcknowledgment of Receipt of Materials <br /> U <br /> � Transporter I Printed/Typed Name <br /> Signature Month Day Year <br /> 0 ­j <br /> > <br /> Z <br /> Transporter 2 PrintedrrypecrName Signatq(p,,,,,- Month' Day Yeaf <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> El Quantity El Type ❑Residue El Partial Rejection El Full Rejection <br /> I Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 0 <br /> 65 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 <br /> LU 1• 2. F <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Year <br /> Name Signature Month Day In I <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COP) <br />