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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) v l' Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST (:ALCM-31+�� Q � "�J77"Z- R 0001194:12 DAT 5.Generator's Name and Mailing Address Generatot"s Site Address(if different thaninailing address) jAc-t'"e *vc» MC_ .1�t4Z 17:00D i SEiiRV ilc E QT'S t�t4 bEl{ZL y cam• IS!,O - X21—'75 -i "TR&C-y CA q 5'30` 209 XZ 1- -754-1 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number ST+ itI cV c jE SPM4 h-LTJ VjAST—E 501I~csTi 5ni$ r 1Nt-- s coC> t(09;L 7.Transp er 2 Co pang ame U.S.EPA ID_Number 14 1JO ts�3� 1 8.D ignab d Facility Name and Site AddressU.S.EPA ID Number C F i �htV�Rr+tJ Mufti�ti- T o F �3;CtI 1kU!'� L 1..C Aiv A-780 Bg 5"33 N 6�.AN oS dtL, cA s r Q /47 b Facility's Phone: J 7S 2-7 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID.Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type 11 Quantity Wt.Nol. 1j f®wj Q c..ek Lt t?A to #S3 UA 2�Li- P 2. .KC H 1Z4LQA NAIAA DOV5 wikSW X14-JO i-3,3 m 135 ---m- 1 # 4. iw 14.Special Handling Instructions and Additional Information i MP 2 —c7 MP14,6 "Z cam � 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper pping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition#or transport according to applicable international and national governmental regulatiotl.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the of the attached€PAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262 }(if i am a large quantity generator)or(b)(if I am a small quantity generator)is true: GeneratoeslOfferor's Printed/ryped Name Signature } Month Day Year ` tb -1 16.International ShipmentsR F- ❑Import to U.S. ❑export from U S ort of entrylexit: Z Transporter signature(for exports only): x1: m Date leaving U.S.: W17.Transporter Acknowledgment of Receipt of Materials W. Trans rter 1 PrintedRyped Name ' Signature �t Month Day Year cL ,�a (IV N �, C 18 QTrans p 2 Print yped Name Sign re Month Day Year 1 If Discrepancy Lifer it 5�'WJ1L� 1^�rtCt1 ett❑,'parti�al R j ct�1n ❑Full Rejection 18a.Discrepancy Indication Spa( ResidueI > 7❑ Q'� th- f1U� om! v� �� Re Cr&Lwt &Y Manifest Reference Number: Sir „ C O`J ,31 ETA ID Number 18b.Alternate Facility(or Generator) J Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) s a Z N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4. LU 1 2. 3. 20:' grated Facility Owner or Operator.Certification of receipt ��ardous materials covereit t man'rfest ex pt�as noted in Item 18a Month Day Year PrintedlTyped Nam s; Signa ure ) p EPA Form 8700-22(Rev.3-05) Previous editions are obsole 3 IGNATED FACILI TO DESTINATION STATE(IF RE tUIRED)