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Ptease print or type.(Porn designed for use(A elite(12-pitch)typewriter) t ( i, ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'Generator Number 2.Page 1 of 3.Emergency esponse Phohe 4.Manifest T <br /> r <br /> acking Nuber �/ <br /> WASTE MANIFEST 10166741352 JJ K <br /> 5.GeneraWs.Name and Ma�ifgAddress Genera s 5 cess(if different than ma rg address) - <br /> P �x�f77�1a�l�C: <br /> Gert atofs l'honer i n_ SWC400.CA 95 <br /> $.Transporter 1 Company Name U.S.EPA fp Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> e B.Designated-FacihtyName ani:M-Address U.S.EPAIDNumber <br /> Faai ty's Phone: 41 19-1-M <br /> 4a. 9b.U.S.DOT Description(including Shipping Name.KIZ3rd Class,ID Number, 10.Containers 11.Tota'. 12.Unit 13.ylaste Codes <br /> HM and Padurig Group(d any)) No. Type Quay WtNol_ <br /> a. 1. r r', ."r'%s• D";t?'>rF�.�ct'is`ijfUtfilS:fiS' i :'fid { .�'� i i <br /> w <br /> Z 2. <br /> LU <br /> fD <br /> 3. 4 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Will <br /> r' <br /> 19 <br /> 15. GENERATOR'SfOFFEROR'S CERTIFI TION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are lass..ed,packaged, <br /> marked and labeled/placarded,and are H.A respects m proper condition for transport according to applicable intematonal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this 0onsignment conform to the terms of the attached EPAAdonw"meet of Consent. <br /> 1 certify that the waste mitim¢ation state t Identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. - <br /> GeneraWs/pflemts PmbD&Typed Name i Signature Mordh Day Year <br /> —r 16.International Shipments <br /> Z ❑I to U.S. ❑Export from U.S. enbylexit <br /> Transporters grab.(for exports only): to leaving U.S.: <br /> 17.Transporter Adamwledgment of Receipt of <br /> Transporter 1 Prinled(fyped Name Siomiure / i Month Day Year <br /> IL <br /> fr <br /> ZZ Transporter 2 PrkttedrTyped Nam — Sjg9&re Morrth Day Year <br /> r <br /> 18.Discrepancy <br /> 1 <br /> 18a.Discrepancy Indication Space <br /> ❑ nlity ❑Tvpe ❑Residue ❑Partial Rejection ❑Fu11 Rejection <br /> Mandest Reference Number. <br /> JZ 18b.Alternate Fadfilylor Generates) _ L'.S.EPA ID Number <br /> U <br /> LA- Fadltty's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a I <br /> z <br /> y19.Hazardous Waste Report Management Me"Codes(i.e.,codes for hazardous waste treatnent,disposal,and reyding systems) <br /> LU 1. 2... 3. 4. <br /> 20.Designated Facility Owner or Operator tion of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Pn med/wl Name 1 r— t Signature Month Day Year <br /> EPA Fortin 8700-22(Rev.3-05) Previous editi m are obsolete. DESIGNATT—D FACILITY TO GENERATOR <br />