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Please print or type.(Form designed.fdr use on elite(12-pitch)type' min) <br /> ) <br /> UNIFORM HAZARDOUS 1•Generator lD Number Form Approved.OMB No,2 05 0-0039 <br /> 2.page 3 of 3. ency Response Phone 4.Manifest'(Tracking Number <br /> - <br /> WASTE MANIFEST `�' k.�����}'Y��, 1 � ��� �.1��'Y�v���J <br /> 5.GanarStors Na a and Mailing Address JK <br /> Generators Site Address(If dffferent than mailing address) <br /> tetlt,�L�'� <br /> CA <br /> e OC i<T�?€ tiiF <br /> Generators Phona' <br /> 6-Transporter 1 Company Noma <br /> ;aK0gLrrigts U.S.EPA IU Number <br /> 7.Transporter 2 Company Name <br /> 11.5.EPA 16 Number <br /> t;.oesig"NOVYMI <br /> U.5.EPA ID Number <br /> 5KILIft V. <br /> +St! t_F*nlCITY <br /> Facility s Phone: : � 1 <br /> ga• Deb.U.S.DOTDescription(including Pmper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packidg Gmup gany)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WI.Nol. <br /> 1• '•'t:<1': ?-s� ►i hts I• I +rts�ice?r�CsC 'rel At VO-AkJ,Q.-. <br /> Z 2. 11t r 11 t 7p�a 50t.rL3+yFri< f vt- X16.. Ott.,s <br /> ru <br /> t9 - <br /> 3. ..3 <br /> 4. <br /> 14_ I Handiin t��aucti �ndAddip 1 In tion <br /> pedal, <br /> �t� •U s3 is ttAIt fvrlfr.lgtbkMl—TE}t15v &r Go;gel. 17,=rytr0016231 Ltd <br /> 'slt;ii[:A$'fd; :(��Lsq�3!4'�'�4"rLT EA1xJ'r'>4lSYF�t:�X <br /> 241-+ CONTACT 04fw?vrit}+..ti lid��" C _'•.•' <br /> 15. GENERATOR'SICFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ane fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport a000rding to appGeabie international and national emmental re utatlons-If <br /> EVorter,I certify that the contents of this consignment conform 10 the terms of the attached EPAAcknu&ledgmeat of Consent g export shipment and f am the Primary <br /> 1 certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quant ty generator h <br /> { Y or (if am a smaN quantity( 9 ty generator)is true, <br /> Generam s10{fcemrs P ir�tadlTyped Name Signature <br /> Manlh Day Year <br /> F16.International Shipments <br /> z ❑Import to U.S. <br /> Transporter signature(for exports only): Exportlmm�l.5. Pod of anng U.S,:it <br /> � Date leaving U. <br /> 17.TransporterActmowledgrrent of Receipt Of Matedals <br /> Transporter 1 Printedfpyped Name Signature <br /> CL �. t,�t ► Month' Day Year <br /> z Trans <br /> Q porter 2 Printedffyped Name 0.1 5ignafure <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quem ❑Type ❑Residue ❑Partial Rejectton ❑Full Rejection <br /> 18b.Alternate Facility[or Generator} Manifest Reference Number. <br /> :3 U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> W 180.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(i-e-,codes for hazardous waste treatment,disposal.and recycling systems) <br /> an-Designated Facility Owner or Operator.Ce0catlon of receipt of hazardous materials Covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name 5ignalure <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />