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Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response' Phone 4. Mt Trac n Number <br /> WASTE MANIFEST UL00023547616 08S 966~7378 an es19 4 3 6 K 2 8 JJ K Y' <br /> 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> VXWT T"Mm Cmalms LTC <br /> 5508 uNI AS IATVE E%YMVr J ?"VEL RLASA 618 <br /> RNW" LLEE , 'H 37909 1501 : .8 . ,TAS 'TCIIiIE ROAD <br /> Generators Phone: 805 4742826 � ' ` t�9lPB RXIIM Cly 95366 <br /> 6, Transporter 1 Company Name U.S. EPA ID Number <br /> ADA giMVIC .SS , XBC . CAR000189431 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> 04T70 - Ili . �L N <br /> 0� .. � �rS'D� <br /> Facility's Phone: <br /> 9a. 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WtNol. <br /> 1 . 0 <br /> wage <br /> JI7T aS' d,RY <br /> Z 2. <br /> w <br /> 3. <br /> 4. <br /> 14, Special Handling Instructions and Additional Information <br /> ,i;:WID MM CONKACT k WAR 911116l3iELk G101i1F'9 1) EOITEE(! MTH ti{5[T33RLtCIEIVZONS <br /> 15. GENERATOR'SIOFFEROR'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 labelediplacarded, and are in all respects in proper condition for transport according to apprrable 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 EPAAcknaxledgment 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 /> Generators101feroes Printed ed Name Sgnature Month Day Year <br /> rJ' i <br /> �j 16. Intema 'onal Shipmen <br /> F— El impart to U.S. ❑ Export from U .S. Port of enfrylexiL <br /> g Transporter signature (for exports only): Dale leaving U.S.: <br /> W 17. TranspoderAcimowtedgment of Receipt of Matedals <br /> Tran sp r 1 Printed/Ty {Jame Synalure Month Day Years J <br /> O j 6' �� 1) <br /> CLInD <br /> aTransp erg r t /Typ Nam Sgnature Month Day Year <br /> 1-- <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Altemate Facility (or Generator) U.S. EPA ID Number <br /> J_ <br /> V 1 <br /> LL= FaclitysPhone: GENERATOR Month Day Year <br /> W 18c. Signature of Alternate Facility (or Generator) <br /> G <br /> N 19. Hazardous Waste Report Management Method Codes (i.e., codes for ha It is your responsibilih' r'0 make a copy <br /> 4 <br /> UJ <br /> s 1 . z. of this "Generator ' s Initial Copy" and <br /> mailwithin 3p days to ; <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazard DTS C Gene tOr <br /> Printed/Typed Name � Manifests onth Day Year <br /> P . O . Box 400 <br /> EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete. Sacramento , CA 95812 GENERATOR'S INITIAL COPY <br />