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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pae 1 of 3.Eme Ph4. aim es Trackin Number <br /> UNIFORM HAZARDOUS g �enc Resonse one a <br /> y p g JJ K � <br /> WASTE MANIFESTrlj, <br /> 5.Generator's Name and Mailing Address ) � Generator's Site Address(if different than mailing address) <br /> 1.ANT#rCy'`,} �y �i-1,'XWAY <br /> MA CA 95336 <br /> Generator's Phone: 833.7107 <br /> 6.Transporter 1 Company Name- U.S.EPA ID Number <br /> .iRONMENTA L SE-PACES "j 77036 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ,;TCI(3 3°! FlLF,NI E�i+�:U i d-CLi:7 <br /> 1f11F'T'4iv CA 902::21 CATv60013352 <br /> FaclliVs Phone: f lid01537-71 on <br /> ga gh.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.IVol. <br /> 1. i f 3.WASTE FLAMMABLE LIQUIDS, NO 3 <br /> 0 `V;0UNF/DfFSEL). 3.PGA <br /> z z. <br /> w <br /> I I <br /> t <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT - c.Iil;h+TREC 1.800-424-9 WOES TERMINAL CFRES CS NAE 96a. 128 *P€OFRE 9BJ <br /> r1LL691-102410 r3A9CXIF#EJ01F9EL * *APPROPRIATE"F FQ"PME'T <br /> 15, GEN ERATOR'SlOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged, <br /> marked and labeledlplacarded,an�:are in all respects in proper condition for transport according to applicable intematianal 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 EPAAclmowledgment 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 /> GeneratorslOffero's Printedfryped Name Signature Month Day Year <br /> 16.Intemational.Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entgexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> u=u 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 PfinledlTyped Name Signature Month Day Year <br /> a f f <br /> CA! <br /> ¢ Transporter 2,Printed/Typed Name Signature Month Day Year <br /> rr <br /> t-- <br /> la,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ 7 <br /> 1:1 Type Residue Partial Reaction j Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> � 18c.Signature of Altemale Facility(or Generator) Month Day Year <br /> Q <br /> z ' <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 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 /> Printedtfyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />