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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.Manlfesl Tracking Number <br /> WASTE MANIFEST C;AI.UE)t}U:�l i i i 1 -' l04 6.194J41 J ! 61 6 r'}3 1 G B F <br /> 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> CiOC;KION[FAG i'WATT R l7JV-TRICT <br /> 67G7 L MAIN <br /> STUt.KIC)IJ (:A <br /> Generalor s PharslFtl9 1139-049J <br /> 6 Transporter i Company Name U.S EPA ID Number <br /> r1fv11::f{IL;PJ�F VAI,I E'Y WA:iE l:OIL_ IN(; U.S <br /> 7 Transporter 2 Company Name US EPA ID Number <br /> t,f E;itlt.YGLi ;:I1I-(;IAI,'I Y LVA::1 F..::ItLEJ"i it lE lam. INC, 1 IS3,E;U01 111Ir24 <br /> 8 Designated Facility Name and Site Address`I..i <br /> (,ENI I tR F- VI1%'Q?LYlklJ l AL Mc M i :Ji- NL-JAL A Ll 1" U 5 EPA ID Number <br /> I1Vf)9i3(1F:y5?38 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10 Containers 11 Total 12.Veit <br /> HM and Packing Group(if any)) No. Type Quantity Wt,Vd 13.Waste Codes <br /> '4 1 Rn NA,tn7t IAAr.ARIWit.let WAc;I'F c.,i(.Ifr,1•I i9 S N Vf;II1,1 F Air. I: 13llul LN10 i VTI <br /> O t1��fi.4f11 <br /> i 2 <br /> UJ <br /> 3 <br /> 4 <br /> 14-Special Handling Instructions and Additional Information <br /> I'i`VI-ILF-ft JLr7f 264)1 fvi:1AE.:,IiAV1C.s3S {ii+�fJ 111 <br /> E ME RC!LNVY(:UNrAi;i E-C) <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this cons gnment are fully and accurately described above by the proper shipping name and are classified packaged <br /> marked and labe ed/placarded,and are in all respects in proper condition for transport according to applicable intemationaf and national governmental regulations 11 export shipment and I am the Primary <br /> Exporter I certify that the contents of this consignment conform to the terms of the attached EPA Acknow edgment of`0-nsent <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 lama smat quantity generator)is true <br /> GerheratoeslOfferors PtinledlTyped Name Signature A Month Day Year <br /> 16 International Shipments <br /> ❑'mport to U S ❑Export Iron U.S. Port of entrylexit: <br /> Transporter signature(for exports only) Dale leaving U.S. <br /> W- 17.Transporter Acknowledgment of Receipt of Materials <br /> tu <br /> 1— Transporter 1 Printedayped Name Signature '—' MDnih Day, Year <br /> 5E Trdiasporter 2 PriniedlTyped Name f Signature Month " Da}/ Year <br /> 18 Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Res'due <br /> yp El Partial Rejecisorh ❑Full!telethon <br /> Manifest Reference Number. <br /> 18n.Alternate Fadi,ty for Generator) US EPA ID Number <br /> J_ <br /> tl <br /> U. Far"ility's Phone <br /> W 18v Signature of Altemate Facility for Generawr) Monih Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(he.codes for hazardous waste treatment,disposal and recycling systems! <br /> 0 1 z 3 Notice: State of California requires <br /> generator to photocopy and mail to <br /> 20 Designated Facility Owner or Operator Cer0cahon of receipt of hazardous materials covered by the manifest except as nded In Item 16 DISC With 30 days: <br /> PrihtedJTyped Name Signature <br /> P.0 Box 400 <br /> Sacramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev 12.17) Previous ed lions are obsolete 05NERATOR'S INITIAL.COPY <br />