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t ,1� AV <br /> Please print or type.(Form designed for use on Mite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> OUS <br /> UNIFORM HAZARD1.Generator ID umber 2.Page 1 of 3.Emergency Response Phone 4.Manife1st TrwM NNumber <br /> WASTE MANIFEST 4AI4 .,,L i �.3 F� QK <br /> ._ <br /> eInd MatlingAddress dt(dianmadrgadd—) <br /> ' � _ .H'111fl1'laa6et- r <br /> CA.L0004 S M <br /> 7.Trmspdrfa2CdnpatT?LI'Tip i U.S.EPAIDNumber <br /> 1.LC U.S.�1ltDtlurber ;. <br /> Sa $1 bbf bmo;drSlit S�irg 66rt Hamid C m hf artier, 10_Panha le+s 11.Total 12 Unit <br /> HM �PIditGm 4�ANH - No. Type Quantity WINof- 13.Waste Codes <br /> Q. 1. w-w"A HwwdmnSw{p4er57 rrVDobrFs) 1 C-M T III j <br /> p <br /> LU 2 <br /> W <br /> t � - <br /> I <br /> 14.Special HandGg instructions and Addifroral - <br /> M�tt�•1� <br /> X15. S CERnWA :I hereby declare M the coWe&of fMs canWowd are hdlg and aonuafely desadW above by due proper stripping name,and am dassAM.Padmged. <br /> nerW and la6ekdrpfatarded,and are in of Tospectsin proper condition for transport.according to applicable ireerrrabanal and national governmental regulations.If export st im"t and I am the Primary <br /> banter,I cmtfy that the wNents of to cons gnmerd cadorrn to the terms of the a7ached FYAAdmowWgmeM of Consent <br /> I ca5fy that the waste mkiimization staff in 40 CFR 28227(a)fd I am a large quwlity generator)or(b)('d I am a small generate is true. <br /> GeraWdOferoes PrirtedfTyped Name _ SWature Mash Day .Year <br /> - (A <br /> J 16.IntematiadShipments - <br /> i— ❑iifpartlio U.S. ❑Export tiara US. d a"exit <br /> z Transporter signature(tor exports arty):. Dale Waft U.S.: <br /> w 17.TrarrsporterAdmvrledgmerd d Re!a9t d i <br /> Transporter l PdntedrTyped Nairne Monti Year <br /> a <br /> -11ICZVI .6t,r a ;� /6 1 1/ <br /> Z Transporter 2PrmledfiypedName Month Day Year <br /> 18.DisrJ ncy _ <br /> 18a.Discrepancy Indicaf Space El Quarrtby ❑Type ❑Residue ❑Partial Rejection ❑Fut Rejection <br /> Manifest Reference Number <br /> 786.Altemate Fadfdy(orGenerator) U.S.EPA ID Number - <br /> J_ <br /> V <br /> F.Ws Phone: <br /> w 18r—Signature of Anemate Fadtity(or Generator) Mmlh Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method qodes(i.e.,codes for hazardous waste treatment,disposal,and recycirg systems) <br /> 0 1 3. 4. <br /> 20.Designated FaoTdy Owner of Operator of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinteNfyped Name �� Sgnairre Mmlfi Dir Year <br /> `/�f G{[ ) <br /> EPA Form 8700-22(Rev.3-05) Previous editions a obsolete. DESIGNATED FACILITY TO GENERATOR <br />