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Please print or type.(Form designed for use on Olite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID r 2 Page 1 of 3.Emergency Response Ptwr a 4. 6gj1 <br /> WASTE MANIFEST1, 614 wand" 7 <br /> 5-4&w. .`ane and Mailing Address j"6 dierent then ma ft adds) <br /> _ v �t CALWOdiE�S <br /> 7.Trans)wIerTCanparyNaha U.S.EPA ID Number <br /> 9� *t&Wr&ftq"'OdiftPwP&s*PirrDarue,Hazard toss,b Number, 10.containers 11.Toted 12.unit <br /> HM and Pad`rg�w Gya�+N No. type wtAld. 19.waste codes <br /> 1 t�4Cy1 R• rt4 y�+xdkxts Y�'t3St9" ;�s ,1( Qpt1F18} 1 <br /> Cm T 152 ( � <br /> Uj <br /> 4. _ <br /> 14.Spedal Handling Instructions and Additional Irribmiation - <br /> C-Ki#R 171 iMl►atr PMPW P.P.E. f—CM41MI80 _ <br /> 10 <br /> 15. G ibR'S10FFEVM'S CERTIFiCAT":I hereby declare that the contents of this misigranent are fulty and am ura"described above by the proper shipping inane,and are classified,padraged, <br /> marked and tabeled/placaoded,and are in aA moe&in proper condition for transport amording to applicable intemalionat and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I catify that the contents of the consIrnierd conbrm No the terns of the attached IPAAdmrnNeogment of Cons, <br /> I certify that the waste mi imimtim statement ideritified in 40 CFR 26227(a)(it I am a large quaff*generator)or(b)(dl am a small geteralior)is Yue. <br /> Geriraabr s10Benxs PdntedfTyped Name SignaWre Month Day Year, <br /> �.�1dt�rla _ u� 11 (21 f <br /> 1 16.International shipments <br /> i- ❑Import to I.S. ❑Fort fmrn U.S. P o(enby/exit <br /> 1 ransporter signature(tor exports only):. Dale leaving U.S.: <br /> IX 17.TrarspoderAdmnwledrinentof Recegl of <br /> IX Transporter 1 Printed/Typed Name trbnth'- Year <br /> Z Traruspaler2 Pr ntedlFyped NA1te ure Month Day r <br /> f- <br /> 18.Discrepenq (� <br /> 18a.Discrepancy Indication Space �b T <br /> ❑ EI ❑Residue ❑Partial Rejection ❑Fu!Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Faddy(orGenealnr)' U.S.EPA ID Number <br /> J <br /> V <br /> .i. Facilitys Phone: <br /> W 1&:.Signature of A tornate Facility(or Generator) Month Day Year <br /> Z <br /> H19.Hazardous Waste Report Management Method Cgdes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certificatioo of mc*of hazardous materials covered by the mxWest except as noted in Bern 18a <br /> PdnterYTyped Name nth Y <br /> P l/! �� O �� <br /> ,it <br /> EPA Form 8700-22(Rev.3-05)Previous editions artli obsolete. D19SIGNATED FACILITY TO GENERATOR <br /> a <br />