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(D 00 <br /> r CD �:: = N <br /> , <br /> O - <br /> , <br /> z <br /> Coo. <br /> O - <br /> Z3 V <br /> D r�F <br /> M �, M. <br /> 'Woo(Form designed for use on elite(12-pill lYpewnEer �'' .--F <br /> �,¢MHATAR�OUS I-GenerakorlDNumber <br /> QST€MANIFEST <'nage t of 3 E 11 Ap¢1+10 OW r;c`25-":3� �� !�•�, <br /> m"9""ty Ras Po Rion 4.1il +!r,xr,�ge�fi.r <br /> �,-emtors Name and Mailing Address t $F rte+ <br /> GeneratorsSde AddrgSs la a!€krenrmr mµng■dbe>ts r�� CD <br /> Generators Phone C <br /> 6.Transporter 1 Company Name O <br /> U.5 FPA ro Kir4rs <br /> 7 Transporter 2 Company <br /> US EPA t0 r4r.Ar1 <br /> -- <br /> 8Designated Facility Name and Sile Address ^ <br /> LLS EPAtD Numbd F... [,t] <br /> -D <br /> Faabtys Phone. CD � <br /> ga Bb.U.S DOT[)ascription pnt3ud€ng Proper Still Name.III C€ass.19 Number, 10.containers it Tau! 12 a, - ...... - 0 CD <br /> HM and Packing Group lsany{I No Type ❑uanGly m'vu CD <br /> K �F <br /> 4 0 <br /> w r'7 C7 <br /> Lu C) <br /> C7 <br /> �• C <br /> V � <br /> O 0 <br /> r--F <br /> 14.Spain Handling Insaucttans and Adddfonal Information O <br /> d 0I--I <br /> 15. GENERATOR'S10FFEROR'SCERYIFICATION:Thereby declare that the wnlents of thls consignment are fully antl auura!ely tlesariped above6y Ne proper shipp�egna0iV are Uasafred, V <br /> marked and EabeledlPiawrded,and are m all respects in Proper eondith n for lwsport ame,dmg Io app6rzNe international and national governmenul regulations II exponshipmen!antl I am 1hR ^ <br /> Expoder.I aearty that Ne wnlents of this wnsignment conform to the terms of the attached EPA Acknaerate�nt[Consent. eratori r vue. 1 ^ <br /> >dooth Pav tient \1 <br /> I certify that the waste minimization statement idenh6ed in 4t1 CFR 262.27{ai(if,I am a large quantity SignaNm o(b){if I am a smsMl gvanllly gen <br /> Generaleeeroff, rs Pdntedfyped Name <br /> ..r port of eniryleMA'. —� — <br /> 16.In Fnatimal ipme s ❑Expos tram LLS <br /> ❑Import m U.S. 17a1e leaning <br /> z Transposer signature{for exports onlyp, <br /> W- 17 Transponer Acknowledgmentol Recoplof Maledals Srgnalum 0 <br /> Transporter 7 PnntedR�rped Name �+ <br /> ix <br /> !! tknn!h ay ear <br /> Y Transporter 2 Pon rI Name rn <br /> a p <br /> Patliel Re{action ❑Full Ra1ei;4nn <br /> 1--h <br /> I <br /> 18 OisrrePancY I ❑Residue <br /> V p CJ Ouantny ❑Type <br /> 18a.Discrepant Indlralion 5 ace <br /> Manifest Re€erence Number. <br /> LIS CPA ID Number <br /> } 18b. e MernalFacility lar Generator <br /> r +. <br /> J Alonln gay Year n <br /> 1� <br /> ua.. Foci€dy's Phone. <br /> P 18c.Signature of Alternate Facility lot Generator LU <br /> sal,and recyrloq%Y - ' <br /> 3 Notice:State of California requires -� <br /> 19 Hazardous Waste RePor1 Managernent Method Codes lie wd"s for hazardous waste trealmanL IsPu <br /> 2 generator to photocopy and mail to <br /> LU 1 <br /> a edhylhemanife oreplasnotedinitem DTSewith 30day5- t� <br /> Signature <br /> 20 0esignaled Facility Owner or Operator Certification of receipt of hazardous materials wyer p.0 Box 400 n <br /> 1 PrialedffypedNam Sacramento,CA 95912-0400 <br /> . Previous editions are obsolete. <br /> GENERATOR'S INITIAL C <br /> EPA Form 8700.22(Rev3051 <br /> J o CD <br /> 0 <br /> o �1 cn <br /> W CD <br /> N <br />