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CD = o--4-0 <br /> CD N <br /> 0 0 O O <br /> v 0 Q ON N <br /> O O fly <br /> CD O) - <br /> Q - 3 <br /> CCD <br /> M _ - -��. _, IIfI rI 11 v <br /> Please Print or type. I I�I I�I �I CD <br /> p <br /> UNIFORMForm Approved.0Mo No.2650 X39 { <br /> HAZARDOUS 1,Gene afor 10 Number 4.Manor st ra m N h r <br /> WASTE MANIFE57 2 Page 7 of 3.Emergency Response Phone A G J <br /> 5-Generator '-+41 V10044AN`.i; ,,, ``1 b LJ W <br /> s Name and Mailing Address 1 i�" <br /> Garmerathrs Sile Address(if diterenl than mail.ng atldres. <br /> i2a E liar'ney Lr. fr G Iia+ iT 'r t_t. O <br /> Generators prgne: <br /> S.Transporter 1 Com n N MPay ams <br /> U'.5. PAIO NumLv = <br /> D) <br /> 7.Transporter Co <br /> milady <br /> CD <br /> `C <br /> S.Designated Faplily Name and Sife Addressr <br /> U.S.EPA ID Number :3 <br /> Rt,o L.he at LL[: r- <br /> 425 Isis Alii p <br /> Faplily's Phone: IhyJQWOOd, CA <br /> 9a. 9b.U.S.DOT'DPscnptii imdud ng Proper Shipping Name,Hazam Class,ID Number 1 a r v n <br /> HM and Padang Group(if any:q G.Containers 11.Total 12.URn <br /> Quantity Wt''Jcl "'as!=Gcd, <br /> 1 No. TYPe co <br /> p Ul <br /> � N <br /> C <br /> w O <br /> z <br /> w <br /> c� <br /> 3 <br /> 14-Special Handling Instructions and Additional Information - ,.,ty . <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are futy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and febelea'plaranled,and are in or respects in proper condition for harlsport according la applicable intsmational and national 90VOinn nlal regulations-If export shipment and I am the Primary <br /> Fxpomen,I COrtify that Ne=ants of this consignment conform to the terms M the attached EPAAckwMedgmed of Consent. <br /> I certify thal the Waste minim¢ation statement identified in 40 CFA 262.27(a)(if I am a large quantity generator)or(b)(ill am a small quantltygeneraforj is hue <br /> GenerdloNofferors PnntedrTyped Name 5gnatum <br /> *� ! Month DaY Year <br /> 16-International Shipments 01 17 <br /> z ❑frni to U.S ❑Export from U.S. Part of Erg —E <br /> Transporter signature(for exports only): Dale lea <br /> w 17.TransponerAdrnovAmd men)or Receipl of Melenats <br /> Transporter 1 PrinledlTyped Name Signature/ <br /> CIL Month Day Year <br /> M Transporter 2 P-nledlTypetl Name Signature 41 - <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residua ❑Partial Rejection ❑ CD Full Rejection C 0 <br /> hlanifesl Reference Number, <br /> }gp AliFaaldy(or Generator} D Q <br /> � U.S.EpA ID Number I _ <br /> U <br /> nam Faabiys Phone = <br /> F18c Srgrai ofAllenrale Facildy(Or Generator) N <br /> a Month Day Year Q <br /> Z O <br /> T <br /> SL, <br /> 3 @ Hazardous Waste Ration)Management Method Codes(i.e cotles far hazardous waste heathsanl,disposal and recydirg syslems) C <br /> CQ !7 1 2. 3. U) W <br /> O <br /> C5� <br /> O 2U,Dasiprrafed Facility Owner or Operator Cerldicabon of receipt ofltazardous matenats covered by the manifest except as odea in Ilam 18a W <br /> .O-. <br /> �+ PrilrairdiTyped Name Signature CD <br /> M <br /> EPA Form 8700.22(Rev.12.17) Previous eflons are obsolete. <br /> ERATOR'S INITIAL COPY <br />