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85/08/2013 11:47 323261,'
<br />■nk.4ft'jfit a lypt. (Fo.,m designed for use on elite (12-1)kh) 1VOW/ritoar.)
<br />PRR SYS DIV
<br />PAGE 01/02
<br />EFAFoim 8700-22 (Rev. A5) Previous editions are obsolete. TRANSPORTER'S COPY
<br />-77-p-07UtS: 1.G8neralolJDNumWrc VI. -V No, zuou-wj�l
<br />HAZAA Page lof 3.Errt,-jq",ryResporjseRDM 14. Manifest Tracking'Numer
<br />12,
<br />;A T 96
<br />Iff , S A-�,7 6 0 1 00,7 JJK
<br />,21091
<br />4 Gerpalo(a Name and We pqAddfess Generators 81eAddiess (raiffeient than ma," address)
<br />0001,' ' S OP TRACY
<br />.4.30 AUTTI PLAZA 1AMY O -U 1.10
<br />TRACY, C -A -R� b -5 0 4,
<br />Generalri(s Phoria:
<br />6. Transporter 1 Company Narria
<br />vitt_, ' F 1:t. C 0 A S T 1,A 0 V F- I U.S. EPA ID Number
<br />7. Transporter 2 Company Name U.S. EPA ID KTM",
<br />B. Designated Fadlq Name and S41aMolim
<br />Plic-IFI-C RZ.FJOURce U.S.EPAIDN'umbei
<br />-'QbOr E.ASr PICO RLVO.
<br />(.05 t) Pj (-OF, I,. C. J1
<br />FacR �s Phone: O"WO) P919-71jlb
<br />9a.
<br />9b. U.S. DOT DesciiVion (np*d!ng Proper Shipping
<br />hipping Nam,', Hazard Cass, ID Number,
<br />to. Coma (S
<br />11. Total
<br />12. Unit
<br />HM
<br />and Pac'Ong Group (d any))
<br />Qvwitx/
<br />wivol.
<br />13. Wa slg Codes
<br />NO,
<br />Type
<br />YAW.,
<br />0
<br />7T T-
<br />U.1
<br />2'
<br />0
<br />'-XV-Z-
<br />O'Wly
<br />M-11ANING (CAl.1FOPNIA Re(, -;M Milo
<br />ONLY
<br />F
<br />6
<br />14. SPCdW Handfrig Instrucl3ons aW Addi$owl IntormalJon
<br />'I
<br />? -P
<br />6LOVES. WIGGLE,; to PFZ0TC'CT1V(. UOTMXNG 24HR 11 MF k6[ --1N0' COMI'Ar-1 1-*.,1RK WALOJORF
<br />F'.R09.
<br />7'QANS'.PQR)'FR I PHONE 4-
<br />15. GENMTOIVSIOFFEROR'SCERTIFICAnON: I hereby declare that the contents of this consignment are Aily "accurately dowbed above by the Proper shipping name, and are clanffi;d, packaged,
<br />Marked and lab-led/placardeid, and are in all respects in proper condition for traraporl according to app3caVo kilerria!loinal and rational poymmenU regutabom. 11 export shlpfrent and I am the Pfinary
<br />Exporter, I ceo (hat the contents of Ks const nmenl conform to the terms of tha attached EPAAcknoW&dqraen1 of Consent,
<br />I cerfly 10W the waste rrilmm*alion statement Tdontfied In 40 CFR 262.27(a) (V I am a large qu3nW generates) v (b) (d I am a..sor'o quantity generator)
<br />Name aloe In I Day Year
<br />Month
<br />t 11/;j 971/
<br />--j
<br />1%-
<br />16. Irbleirrabonal Shipments
<br />11 knPl to U.S. Exp,d from U.S. PO4 of env-�it
<br />':�
<br />Transporter sgnatune (for exports only): Dale leafing U.S.:
<br />Ce
<br />Ce
<br />17. Tr2mprxWAdor"ledgrnen1 of Recelpt of Materials
<br />0
<br />TranspoYl I Printed Typed Mame Signalure �IOM4, �y
<br />A/
<br />zQ
<br />Tfawporlw 2 PrinliatOyped Name lure hiojM Day Year
<br />18. Discrepancy
<br />i ft Disctepancy In6calion Space El Type E]Pa.Ul Re;aclkrr El Ful 13,1,6on
<br />Blankest Reference Number.
<br />I alb. Aftttnate FacirAy (or Gerieralw)
<br />U.S. EPA ID Number
<br />LL
<br />Fac&Ys Phone;
<br />01
<br />uj
<br />18c. Slgnal,,qe of Adlemale Faddy (or Generator)
<br />hicia Day Year
<br />F-
<br />19. Hazardous Waste Report Management hfetW Codes (Le,, oodes for hazmdowAlaste Ireatnient, ftpoiW, &rvd recydng systems)
<br />LLI
<br />i.
<br />2,
<br />T
<br />20. MsigrAled Fad5ty Owner or Operaloc: CY;llcalion of receipt of hazardous rnalerials ca%%ar&J by the raolfe5l: excep(a5 noted In Item 18e
<br />Print ,d Nane ...,- SlonalkIre
<br />f".' / --? Jorth Day Yea") -A - e
<br />4>0 ; I1 r
<br />.
<br />EFAFoim 8700-22 (Rev. A5) Previous editions are obsolete. TRANSPORTER'S COPY
<br />
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