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P easer1nt or lypd``(Foran designed forlse on i'it�(12 pitCI) lVY 45 �� <br /> UNIFO AZA 2DOUS 1.Generator ID umber 2.Page 1 of 1 Em�Response Phone 4.Maf lfas ItWing Number v <br /> VII EUANIFEST (;A1^GJ(?+4� 7!F �s i.•°f3 JGJw�4 »- �I( r k JJK <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> J <br /> LW f <br /> Generator's Phone. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Iz.l..wt?y"R J.'. ITEC^' V4 R w;t!�k a c > > <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 /> CA JR S: !iLt'.Vi.A �a 2WCF.,; �•�I <br /> C6 99023 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10^Containers 11.Total 12.Unit a <br /> HM and Packing Group(if any)) No. Type' Quantity Wt.Nol 13 Waste.Codes <br /> T'F PAT.NT RFci..A I'IA`fTE'RIAL. 1. � <br /> y ... <br /> I 'C <br /> UJ 21'r'ta: RC RA HAZARDOUS WASTE LIQUID (WATERBURPNC i s:> <br /> �il 1t tNf;7 ,10( i :tONi (CALIFORNIA REGULATED ��� , <br /> J U <br /> 4. <br /> 14.S pecial Handling instructions and Addttional Information <br /> y r . <br /> - <br /> iltf PROT CTIVE (,'LOTHINO r5Ifi1P FMVIRCIF_(ra(Iy ++Gtttt <br /> (�(f41"(it,-( J�K K (41M, tl i <br /> 101 <br /> 4tt� � t � ` 9 3 E 1, <br /> it R <br /> 15. GENERATORVOFFEROR'S CERTIFICATION: 1 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 labelediplacarded,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 terms 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 /> Cie rator's/Offerors Printedfryped NaeSin re ' ` a <br /> fiL Month F Dayr Ye <br /> - 16.International Shipments k) <br /> Z LJ import to U.S. ElExport from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Ac nowiedgment of Receipt of Materials 3 <br /> t2 Transp. r Printedfryped Name - �gnatu <br /> 0 � � �!� I � � S �� ohth Day Year; <br /> e f/ y j� 0r t, t f a <br /> Z Transport r 2 PrintedlTyped Name tune / ( t� J5 Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy.Indication Space Quantity ❑Type EI Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> Imo^ 18b.Alternate Facility(or Generator) <br /> If,7 U.S.EPA ID Number <br /> _J <br /> V <br /> w Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Monlh Day Year <br /> a <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes(I^e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifestex pt as noted in Item 18a <br /> Pnnteq/yped Name ! Signatur ' <br /> f. r'' r` Month Day Year <br /> /r <br /> EPA Forff 8700-22`(ReV:3-0 Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />