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Please print or type. (Form desiqned for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1.0f <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />J J K <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />'tom <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />,t FAf9TFCH <br />ENRARONMENTAi <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address _ TECH ENIAITIIONfAENTAL. y U.S. EPA ID Number <br />2t7 MARTIN RD <br />IRV,-1N'01kLF CA 017rt USA <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. <. <br />O <br />_ . <br />z <br />2. ;+ 0 -RCRA H#ZAR.DOUS WASTE SOLID (OILY SOLICS VVASY&,i),�iLD <br />c7se7Al„ <br />n11 =1LTEtiS) <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />Z w�.SS9i3 4Fi'.�------rUSE GLOVES AND GOGGLES TANKE7- t <br />w <br />''_"i4f'ttf tjr (META,- Ffi-TftS) <br />'TALLER MUST IDENTn' CLE RTECIi EMS RONMENTAL AS REGISTRANT: INF'OTRAC 000-535-5503 <br />15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Printed/Typed Name Signature Month Day Year <br />H <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />CL <br />rn <br />Z <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />F- <br />18, Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />A. <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />