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V <br /> A, <br /> Please print or type.(Form desgned for use on elite(1 -pitch)typewriter) l/ Form Approved.OMB No.2050-0039 <br /> -UNIFORM HAZARDOUS 1.Generator ID Nu Z.Page 1 of 3.Emergency Response Phone 4.Marr <br /> 166 4353 WASTEMANIFEST k. t �(r�1 JJ <br /> 5.Gerwr�,-and Maihng Address s (rf dfierent than marling address) <br /> Generators ( CA 9M <br /> a� <br /> PhomK <br /> 6.Transporter 1 Company Name`. "US EPA ID'N*A%r• -; <br /> 7.Transporter 2 Company Name U.S FPA ID Number <br /> rhmn <br /> kwbarssaw"WW LLC. l CAO T9zle <br /> 2MW"L13ialtlrt ft <br /> Du*W*M*,CA QM <br /> Faa>dys Phare: i-742-6P <br /> ga. 9b.U.S.DOT Desagrbon"(ndudng Proper Stepping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Padang Group(d a'1Y)) No. Type Quantity Wt1Vol. 13.Waste Codes <br /> 1. ? f F?t 4,m as VY9sl19 olkl{Filtsr rhAxis) i . C!A i 32 l <br /> W , <br /> ------ i -..____ -- <br /> I <br /> f <br /> 4_ j <br /> 14.Special Handling Instructions and Additionallnforma' n <br /> 15- GENERATOWS/OFFEROWS CERTIFICATION: I hereby declare that,the Contents of Otis cormNnment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labek dplacarded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations.tf export shipment and I am the Primary <br /> Exorter.I certify that the oordents of this consignment conform to the terms of the allad*d EPA Admowledgrnerd of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(K I am a large quantity generator)or(b)(if I am a small Wtity tor)is tpne. <br /> Gene } Aa <br /> Ag 7' <br /> ri 16.International Shipments <br /> Z ❑Import to U-S- ❑Export from U.S. PA of entryleAt: <br /> Transporter sgnaiure(for exports only): Date leaving U.S.: <br /> w 17.Transporter Adurowledgment of Receipt of Matenals - <br /> Transporter 1 Printed/Typed Name Signa �1 Mo/nth+ D Year <br /> Z Transporter 2 Pririn ledlTyped Name nalure Month Day Year <br /> a <br /> 9x <br /> 1- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Futi Rejection <br /> Manifest Reference Number. <br /> 18b.Aftemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ta+ Farflitys Phone: <br /> th Day Year <br /> W 18c.Signature of ARernate Facility(or Generator) Mon <br /> Q <br /> Z <br /> y 19.Hazardous <br /> ' zat,dand Waste Report Management Method Codes(Le.,codes for hazardous waste treatment, arecycling systems) <br /> 1 't i3� 2. 4. <br /> 20-Designated Facility Owner or Operator.Certification d receipt of haardoys matelots covered by the manifest except as noted in them 18a <br /> PrtnledlTyped Narne Signalurn Month Year <br /> a � c to <br /> EPA Fonr,8700-22(Rev.3-05) Previous editions are of solete. DESIGNATED FACILITY TO GENERATOR <br /> s <br />