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Please print or type.(Form designed for use on elite(1 -pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> I UNIFORM HAZARDOUS 1.Geneator ID NunI, 2.Page 1 of 3.Emergency Response Phone 4. 1 <br /> V 9M�15 V J I <br /> WASTE MANIFEST} <br /> 5.Generators Name and Mailirg Address 4 544 mom <br /> erieraws WeV&e=(tcWaenil tlen ffiJbig address) <br /> � <br /> �LLC. <br /> Gra aoCA ! - <br /> Geaeabrs 9411+1 C!F sm <br /> 6.Ttarsporter 1 Cwpiny liariie U.S.EPADNumber <br /> Yrkim Tt'irT3OV# lat�E41'Ei <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CWM$L13T. 'Nairieapd�te�A"�9ress t��i <br /> }11� � iTXJi� <br /> CA 93M <br /> ga 9b.U.S.DOT oescriprnn(rrdudng Proper Stippimg Name,Hazard Class,ID Number. 10.Containers 11 Tera) 12 Unit <br /> HM and Padang Grorlp(dam)) No Type Quantity Wim- 13.Waste Codes <br /> 1. 111 R+--RA HsmTII i Westill,tadPI 91) CM P 352 <br /> Z 2. <br /> t <br /> 3. <br /> j <br /> r <br /> 4. i <br /> 14.Special Handling Instructions and Addif'lonal Information a <br /> 11!i 7�{I�Sv�e i1�•H 1+��!�2��i�(�<in#��}170392 <br /> 15. GENERATOR'S(OFFEROR'S CERTIFICATION: I reby declare that the centents of this con'of lent are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and lacanded,and are in all m condition for bw according icable international and rational governmental ulatons.If export shipment and I am the <br /> P resp"� PrWar � MJ spa 9 fe9 � Prrren Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Aclmowk igmeod of Consent_ <br /> I certify that the waste minim¢ation statement idelmtififd in 40 CFR 262.27(a)(d I am a large quantity generator)a(b)(if I am a Vantity generator)is true. <br /> GeneratorslOHmors PrintedRyped Name Signature Month Day Year <br /> ,Iwo X"amiltt Lk V\ 1 <br /> I� 1 <br /> 16 Interna"Shipments El Impart to U.S. U Export from U.S. of entrylexit <br /> K Transporter signature(for exports only): Date leaving U.S.' <br /> W17 Transporter Acknowledgment at Receipt of Materials <br /> Transport ypedName„_ '.$gnature Month Day Year <br /> Z Transporter 2 Pnnted/Typed Name / a rem— Month Day Year <br /> ee <br /> 18.Discrepancy <br /> 18a.Discrepancy Indicaton Space Quantity ❑Type Residue ❑Partial Rejection 0 Full Rejection <br /> Manifest Reference Number. <br /> 18b.Ntemate Fadldy(or Generator) - U.S.EPA D Number <br /> J <br /> V <br /> LL Fadlitys Phone: <br /> F18c.sgnanue of M—date Fa lity I-Com,«gent 61or tfm Day Yea <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 )3� 2 3 4. <br /> 20,Desrc3rated Facility Owner or Operator Cerci icafion of reatipf of hazardous materials covered by the manifest except as noted in Nem 18a <br /> Prinledff"Name Signature Month Day Year <br /> —71 <br /> EPA Form 8700-22(Rev 3-05) Previous editions are o ete. DESIGNATED FACILITY TO GENERATOR <br /> s <br />