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Please print or type.(Forfn designed for use on elite(12-pitch)typewriter.) : Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone q.Manifest Tracking Number <br /> WASTE MANIFEST C2R000220046 X09— E34- 9$4 , .. FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> fta?'Lf1I.f =:IkV1i' 10111 TJ L V ' 107 5 =/ :TYI`f ATT"a'I`I-V '1?)JY,a <br /> t'It�'/ ;.ttt1'1st �f f tiil,i 9' 1.17.. cF, it• f1.l.1it1 a1t1t'.;.. T. .1fti (..\ .ir�r �'� (aY,�;;(�. ! ,( irlF_ t1„, J-rk) <br /> Generator's Phone: .'.f3` fr `I^ r1Ort <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> IPTDUz.;7'£t.t.r•1HASI.t1'; U'1'LTjIii:�`�'IIOff, DIC CAD9,80 5 852 9 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPAID Number <br /> Pjlo--�Cmiu 'LLC <br /> 425 5 i': SVG, <br /> 114GIX'Wt7OD CA ' 0301 <br /> Facllity'sPhone: 32,3716233 C908364432' .. <br /> ga 9b.U.S.D0T Description(Including Proper Shipping Name Hazard Class,ID Number, 10:Containers 11,Total 12.Unit <br /> HM `and Packing Group(if any)) No. T e :Quantity. 13:.Waste Codes <br /> Type Y WL ol. . <br /> pX t7�'! stt �Y;«; bra <br /> �.. 3. tTtT1J50, Asxbsalsr (non fl6ibraAbl:e,; teach not 331. <br /> L,XCe�'Ci�I1Q 1' L t7st1a�7jlj r 2.` ' <br /> 03 <br /> 4. <br /> 14.Special Handling ristruchoris and Additional Infofrnation <br /> 1 3�e5U "e." <br /> > . ' . "#('�`"9.'�." 3) zp pepper pz�y':ae 090107866x.73 X00, ERG �.: 1�s <br /> 15. G,ENERATpR'S%0 ROR S CERTIFICATIOr.N: I 1.hereby declare that the contents of this consignment are fully'and accurately described above by the proper shipping name,and are classfied,packaged td. <br /> marked and labeledopparded and are_im1all respects in proper condition for transport according fo applicable;iiitemational and national govemmental regulations:'if export shipment and l am the Primary <br /> Ezporfer I certify That(he contents of this consignment conform`to the,lerm's of the attach"ed EPAAcknovdedgment of Consent <br /> I;certity that.the ste minimization statement identified in 40 GFR 262,27(a)(if(am a barge quantity'generator)or(b) if f ama small quantity generator)is true.. <br /> Generator'slOffer s nnted A�J!Jme tgnalure'° on ay ear�. � • <br /> 1 <br /> � 16.Internah al Shipments -` <br /> F- ❑Import to U.S. Export from U.S. Port of entry/exit <br /> � <br /> - Transporter si nature for exports only) Date leaving:.,. <br /> W 17.TransporterAcknowledgmentoff2eceiptofMaterials <br /> Transporter 11 Pnnted/Typed Name SrgnPt Mont Day ear <br /> ransporter 2 Printed/Typed Name Signature' Month .Day Year. <br /> bp <br /> 18,Discrepancy, <br /> 18a.Discrepancy.Indication Space ❑ Quntity ❑Type Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facilit s Phone: <br /> U, 18ci Signature ofAllemateFacility(or Generator) Month Day Year <br /> Q <br /> z <br /> I E <br /> 19:Hazardous Waste Report Management Method:Codes(i.e.;codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 20:Designated Facility Owner or Operator;Certification of receipt of.hazardous materials covered by the manifest except as noted in,Item 186 <br /> Printed/Typed Name Signature" ' Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete: DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />