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Please print or type. <br /> P5. <br /> ORM HAZARDOUS 1.Generator ID Number Form Approved,OMB No.2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> STE MANIFEST' 'viN tt3. s1 <br /> erators Name and Mailing Address G B F <br /> r,I z � Generator s Site Address(it different than mailing address} <br /> Generators Phone: <br /> 6.Transporter 1 Company Name <br /> ' � LE:`r' �#t �-}r .res U.S.EPA ID Number <br /> 7,Transporter 2 Company Name <br /> "Ohl-L 1LYLIi9�if f�FtY�1r+,IFU&jtf& U.S.EPAIDNumber <br /> 8,Designated Faci€ity Name and Site Address <br /> t-WA Yk-S tflitA.i7 k P$ +Ist i f? t ,, U.S.EPA ID Number <br /> 4UW QS r*SAY 6e,`5 <br /> Faciiity's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)} 10,Containers 11.Total 12.Unit <br /> No. Type Quantity Wt. 0. 19.Waste Codas <br /> d. 1' �a,' tR,"'5t�F#A:°�^p3k MSr.i t��:*�fr rkSd rpt! Ay�?�;(7T,}i�.�TFti Tom' •-ipf <br /> o t <br /> TUR x tfiFrt�: i <br /> -- <br /> LU <br /> c� <br /> r <br /> I <br /> 3. <br /> i <br /> 4. <br /> I <br /> 14.Spectral Handling Instructions and Additionai Information <br /> AAt:ktc s�ti[ Y 0%.*4I AC i AMkR-Af j-i <br /> 15. GENERA TOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuily anm <br /> d accurately described above by the proper shipping nae,and are classified, <br /> marked and packaged,labeled/placarded,and are in all respects in proper cunddion 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 44 CFR 262.27(a)(it I am a large quantity generator)orb iff <br /> Generator's/Offeror`s Primedlfyped Name ( ]( am asmall quantity generator]is true. <br /> Signature Month Day Year <br /> 16.International Shipments <br /> f-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only}: <br /> bate leaving U.S.: <br /> 17-Transporter Acknowledgment of Receipt of Materials <br /> LIJ <br /> Transporter 1 rnmedl7yped Name <br /> Ar <br /> d Signature Month Day Y9ar <br /> Z Transporter 2 PrintedfTyped Name <br /> Signature Month Day Year <br /> 1$-Discrepancy <br /> 1$a.Discrepancy Indication Space <br /> ❑ Quantity EJ Type ❑Residue ❑Partial Rejection ❑ <br /> Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) <br /> z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 <br /> E <br /> 3. <br /> Notice: State of California requires <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a generator to photocopy and mail to <br /> PdntadOyped Name <br /> Signature " ' ' <br /> II Box 400 <br /> EPA Form 8700-22(Rev.12-11) Previous editions are obsolete. Sacramento, CA 95812-0400 <br /> %,�SstCt�W 14JfiC' INI I IAL COPY <br />