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Ple not or ek Fortn desinedforuse on ifs`12= itC�i ewriter. _ A;- m <br /> P tYP C 9 )h ) ,. fir:. app o ec.r4ftr X039` <br /> UNIFORM HAZAADOUS 1 1.Generator ID Number 2.Page 1 of 3.`Em�rgey Response Phone 4,Manifest Tracking Number <br /> WASTE MA"T „' ('AL0?1fL'3:3{) ' 7,151JJK <br /> r:r. <br /> 5 Gener s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 74" <br /> Generators Phone: ;,{,ptr );;r.. pig yt , <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> RE�4),t)�:'t, L l��f i)i.'{k-{i l :��:I'��l,�.f.`�::.� <br /> RE . <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 /> p <br /> r ;r tf/t)1 ' tai i (14 f {� ,.i rti <br /> ,�, �. f ,.i. !•.hilt ., ,lt� '. <br /> Facility's Phone: :. G� r�.tf-•7 +`{;5 <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> F PAINT RELATED MATFRUL., <br /> w RPR 11.17A+{ 77>)US WASTE L.:)QUID (WATERBORNE <br /> (CALIFORNIA FIRG lt,.t`ATED <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> r <br /> ¢ 41 <br /> t /2(.rr,t±d I: F6L1T i 11� C L 0TfIINol EHQI t;{:y (.tsZv't r"itr t r I> r02 NONE <br /> 15. GENERATOR'SIOFFEROR'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 trahsport 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 terns of the attached EPAAcknowledgment 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 /> Ge rator s/Offerors)?rinted/Typed Nae Sin re <br /> Monlh Day Year, <br /> —i'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 /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpditer Pdntedfryped Name ..�»��-*° ~ <br /> O fi ��� gnetur �a Month Day, Yaar3 <br /> QTransportdr 2 Printedfiyped Name ?014ure ,tf Mont Day Year <br /> 18.Discrepancy a <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> J U.S.EPA ID Number <br /> _ <br /> Facllity's Phone: <br /> U 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> i <br /> C <br /> 19.Hazardous Waste Report Management Method Codes(is.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> U 1• 2. <br /> ...� pp 3. 4.. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest ex pt as noted in Item 18a <br /> Printed/Typed Name <br /> • P Signatuf Month Day Year <br /> 'A Form'8700-22�ReV,3-05j Previous editions are obsolete. ESlGNATE®FACILITY TO GENERATOR <br />