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Please print or type.(Form designed for use µelite(12-pitch))pewriter•) Form Approved-OMB No.2050- <br /> f.Generator 1:Generator D Nrmhber 2 Pagd lot 3.Emergency Response Plane w 14.ManJest Toa <br /> WASTE MANIFEST0 1 631 7 JJX <br /> 5 GQ1BCdtoreName and AAa n4Addtess - _ <br /> ' ' Genera s (8 diffraent than mailing address) <br /> t MwIsmn1t L3_C. <br /> F'. .8tr. 372 f l+l: rJa1 (.�1Flt <br /> ,$ #fie. +9f3 t.. ebDCkI!PM.CA 95M. <br /> &T f 1 drrrpayNgg1•J:'_ ,.; 'U.S. <br /> EPA ID Nimiber,' <br /> , t3df <br /> 7.Tianepoder2 Company Name U.S.EPA tD Number <br /> &t>estgit�edFer [jRaneari S�eAddress: f � U.SEPAIDNumber <br /> asiLu(astn��yr4ii rA1 <br /> tiR7527A <br /> CA K2w - <br /> FacJWs Phone_ ' '70-m <br /> 9a: 9b.U.S.DOT Description(wudkg Shipping Name,Hazard Class,8)Number, 10.Containers 11.Total 12 Unit <br /> HM . <br /> and Padang Grip fdany)) No. Type Quantity WLIVoL 13 Waste Codes <br /> 1- '+tC:aAi Mt'F2A f' :c k�°4t.5�e a ;`i i:[tnta,F1'iL7efhx.*i eters} Cm �' 1.LU <br /> W <br /> 3. f <br /> 4. i — <br /> 14.Speda)Handling Nstrtictions and Additional 1 <br /> i <br /> 15. GENERATOR'SlGFFERO"CERTIMA ON:I hereby declare that the contents of this cxps are fully and accurately described above by the proper shipping name.and are cassified,packaged, <br /> marked and labdedfpracarded.and are in 4 respects in proper comMon for transport accodng.papplicable international and national governmental regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the cordenLs d rhos oonW n to the terms of the attached EPAAdutowledgment of Consent <br /> I'oertiry that the waste mi aluat on sta t identified in 40 CFR 262.27(a)(if I am a large quart*generator)or(b)(dl am a smaq quantity generator)is true <br /> GeneraWsfOfierors PrintedfTyped Name Signature Month Day Year <br /> 16.inwmational Shipments:, <br /> Ell U.S. L Fort from U.S. Port of enbyrexd: <br /> Z Traraporlersignature(for exportsow: Dale leaving U.S.: <br /> W 17.TransporterAclaxm!Wgmenl of Receipt of hlal i0-$ <br /> Transporter I P'r'irded/ryped NamSignature �'7 Month Year <br /> QTmnsporter2 Prirdedffyped Name f Sg Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space Miry ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Rebrence Number. <br /> 18b.ABenhale F-1ty(a Generator) —'-U.S.EPA ID Number - <br /> J_ <br /> V <br /> cox FacOiVs Phone: <br /> UJ 18c.Signature of Alternate Faddy(or Generator) Month Day Year <br /> Q ; <br /> Z <br /> F419.Hazardous Waste RReport Management Codes(ie.,codes for tmardas waste treatment,dial,and recycling systans) <br /> 1 0 I j� 2. 3. 14. <br /> 20.Designated Facility Owner orOpmr or.Ce d receipt of hazardous materials covered by the ma diest except as riled in Ilem 18a <br /> Printed)Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions, obsolete. CESIGNATED FACILITY TO GENERATOR <br />