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0 0 <br /> 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 Manifest Tracking Number <br /> WASTE MANIFEST A jj <br /> C% <br /> , I�j _ 1 1 777 002182456 JJK <br /> 5.Generators Name and Mailing Address Generator's�S'r Ad <br /> wwhf�skiw'k , ,f!ess(if different than mailing address) <br /> im , <br /> _406,4 Ka4 <br /> im Shw* fvl S '114-Y'� VIN 1'61170qV 1,1511,7019& I'Ist <br /> F%wt <br /> Generator's Phone: <br /> 6.Transpo r I Company Name U.S.EPA ID Number <br /> 4 <br /> Z/ <br /> 7.Trensporter 2 Company Name -U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> (' 1 ioal W)olle managance, <br /> 35,151 Ohl skyhiw'Rowl <br /> kodlmuw City,(".A 93219 V?I I <br /> Facility's Phone: <br /> 9a. 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 /> 1. I'nVi€ t:trwistaft f1wiltdolu <br /> o N 0AS,9,1 INN P1,Ilk J III, W I f YU (0)18 Y <br /> 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Ptofth-,9: "AXYV1180 FW";' 011`1 <br /> We* 1 0 W1100,ANK169it MWIV601, <br /> f <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents 67 this consignment are fully and accurately described above by the proper shipping name,and are classified,packa ed <br /> �A <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 Primate A <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)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. X <br /> Signature Month Day <br /> GeneratDes/Offeroes Printed/Typed Name Year <br /> of entry/exit: <br /> impo <br /> % o'2 <br /> f R L �I L <br /> P,, ) I��L <br /> _j 10.International Shipments <br /> 1 , AG QZ0 L PA I'a 1 02 <br /> Elrt to U.S. El EExportfrom U.S. Port Transporter signature(for exports only): Date leaving U.S.: <br /> CK 17.TransporterAcknowledgment of Receipt of Materials <br /> 12 Transporter I Printed ad dame Signature Month Day Year <br /> 0 <br /> U) <br /> Z Transporter 2 Print (Typed Name 'Sigrafure Mon tif Oaf Year <br /> < <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> El Quantity Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> FaciliVs Phone: <br /> uj 18c.Signature of Afternate Facility(or Generator) Month Day Year <br /> Z <br /> 3 <br /> 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />