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f l Please print or type.(Form designed for Use on elite(12-pitch)typewriter.) { Form Approved,OMB No.2050-0039. T UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tricking Number WASTE MANIFEST i t � r� �� ;�')��+, �"±�� B 5.Generators Name and Mailing Address 1Generators Site Address(it different than mailing address) - [t ran ea: AN 0 ra71 :.:T WE C;If.: , A 9ss;=1 �T. wf, C:A, ��.:. .. xsao �. .+a.� Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address CAL[FO1j-,,fyU.S.EPA ID Number 5300 C1 AU S KU, r y-0101 aA n4gV7 r+:rx n1„a nnes•a: e, cr t.L4E :TYS4J RIS.•11d, 6 It ;_r,'.+,;J 4..1'it.4/s1e,X-.•'teu�i.si Facility's Phone: 9a. gle.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity WLNoI. '; Z 2. w 3. 4. 14.Special Handling Instructions and Additional Information 41Flit #! 13ojl?YW,4njkI 0705 U-0 i-MI 15: GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelya scribed above by the proper shipping name,and are classified,packaged, `marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international aitlonalgovernmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment;of Consent - I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if am a small quantity generator)is true. - etleratorep flierofsPnnted/Typed Name y JJ Signature Moi Day Year 6.� 7-11 11 16.International Shipments t - t- El import to U.S. El Export from U.S. � Podof entry exit: - Transporter signature(for exports only): - Date leavin U.S.: - w 17.TransporterAcknowledgment of Receipt of Materials' '� - - Ej Tra 4sporte 1 Printed/Typed Name Signature Month -yDay, Year Z Transporter 2 PrintedlTyped NameSignature Month Day Year rY j18.Discrepancy 18a.Discrepancy Indication Space ❑ QuantityT e Residue ❑ yp ❑ ❑Partial Rejection El Full Re(ecgon Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: - w 18c.Signature of Alternate Facility(or Generator) - r a - Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2 - 3. 4. ” ( v� 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in'Ilam iso PrinledlTyped IN a SignaNre r - Month Day Year x �.,. ,' } EPA Form 8701(Rev.3-05) Previous editions are obsolete.( GENERATOR'S INITIAL COPY