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FU�NIFORM <br /> pnn(or type.[Farm designed fflf use an elite(12-pitch)typewriter.) <br /> HAZARDOUS f-Genera f0 Number 2.Pae t of 3.E Form Approved.OMB No.2050-0039 <br /> 9 mermcy Response Phone d.Manifest Tracking Number <br /> WA5TEIRAHIFEST � � 3c'a FLE <br /> erator'S Nemo iltng Agress <br /> �Y"• {a1?rier <br /> Generator's Site Address(if different than mailing address) <br /> CYni � �l #l1 s.5;' TJD c liilr Gener alttf3:':�? <br /> 1201 WEST' AMAIN S RE:E'r lc111I1 WEST MAIN s-rPE:ET <br /> Generator's Phw.re r'2I F'CEI I{ ;:f t ?`i.tityEJ.-302? F+.1�'�IE t, lam' 95366 <br /> 6 ransporter 1 ompany Name <br /> U.S.EPA ID Number <br /> St en2c}'r_le `ruer_ial+v W,,k,te c;r,ittt.i :iris Tl�c S.EPAt2f+NumberrG�'� `�+ <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number , <br /> l�irur 1tiw;.ciF lref c+vFr v '� •_i :�!ns <br /> BDesignored Facility Name and Site , <br /> +lldd rorj i._I_f- U.S.EPA ID Number <br /> i30 <br /> 515924 <br /> . c.+. _r <br /> 24 <br /> ca Rte +ttt�.l5 <br /> 9a 9b.U.S DOT Desviplion(including Proper Shipping Name,Hazard Class,ID Number, 10 Conlakrers <br /> HM and Packing Group(d any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Tyne Quantity Wt.Nol. <br /> It 1NOT1 RCRA ha;:ardoi-ts wastp, 1�e)j_rj ( .;Drt=ct�,Gr I:tF r�� ,1 F+ .?1 <br /> Pr odilct .), <br /> w <br /> LLJz.l�on 1 CRA Ira>arrlr,++- t;,e l:e, a i+ltt�cl tt.ilrr=�.tfaeY' .t }F SAL 44 <br /> FAY"fjt�4.tf,^t c), <br /> 3. <br /> 4 � <br /> , <br /> 14 Special Handling InsWcticm and Additional Inhrrrratlon <br /> t Il ,`.rr it !.i �i: trt ar t a i tJa-r f- (. "r1 1`ir,i ,} <br /> 110524fN'jrr-PCR.W Liquid Watt (C(a ltr,l , i I._rr) .ep,;.r_ <br /> 15 GENERATOR'SFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aad are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable 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 EPAAcknowledgment of Consent. <br /> i. 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator or if I am a small quantity) O( q ty generator)is true <br /> ra.- m s cin yped Name <br /> signature <br /> -` Month Day Mi <br /> J 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U S" Port of entry/exit: <br /> Tran r signature(for exports only): ry _ <br /> Date leaving U.S.: � A <br /> W 17,TransporterAcknowledgment of Receipt of Materials <br /> E2 Transporter 1 Printed/Typed-Name gnature r <br /> O IMonth ay ear <br /> CL "Jeff 1-1j416 11. r <br /> Trar po - arrsP~ I I O i I 'E1 l 4 <br /> ignaturgr <br /> lit all, r , Mon y Year <br /> 18.Discrepancy I <br /> 18a Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> 1 ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> V <br /> Q <br /> LL <br /> WFapl s Phone: <br /> 18c.Signature of Alternate Facility(or Generalor) <br /> ZMonth Day Year <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) I I <br /> w 1 <br /> � � I3 I4. <br /> fica , <br /> 20.Designated Facility Owner or Operator:Certkon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prillipdrryped Name Sagnature <br /> t I J M' Day <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> �'" �)DESIGNATED FACILITY TO GENERATOR <br />