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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HA7ARDDUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST - - 36 6 �� <br /> 5 Generatots Name and Mailing Address <br /> Generator's Sile Address if different than mailing ng address) <br /> I - <br /> Generator's Phone: .. <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> , (',l Eli INIL U.S.EPA ID Number <br /> 6000 88TH S1kLE_T <br /> SACRAPiENi'0 <br /> 92 CA 95811:"8 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(fairly)) 10.Containers 11.Total 12.Unit <br /> No. Type Quantity W[Nol. 13.Waste Codes <br /> ce NON-RCRA HAZARDOUS WASTE, LJ OUTD <br /> 0 (AOUEOU5 HRAKE CLEANER) DF is <br /> w z.NUN-RCRA HAZARDOUS W3SI, <br /> (AOUEOUS FARTS WASHER S0) I.; Iw!) G 13.p <br /> 3. J✓� <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> rgn 3CA <br /> �?1 Iii EMC l,4-NC'Y #1-800-11168-176f) � f � 1 �•.. i � rZ.I <br /> FII µ <br /> `II - �� fFI"f—F ]&.,- v . - � F•. T is I �" i. _ _ <br /> 15 GENERATOR'SIOFFEROR,S CERTIFICATION. I hereby declare that the contents of this consignment are fully and accurately described above by ire proper shipping name,and are classified,packaged, <br /> marked and Iabeleat Oleardetl,and are in all respects in proper conditionfor transport according to applicable international and national governmental regulations.It export shipment and I am th Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> J osp ly that the waste minimization statement menWed in 40 CFR 262.27(a)(if I am a large quantity generator orb if I am a small quantity <br /> Generator'slgReror's Pdnled7fyped Name ) O( 9 ty generator)is true. <br /> Signature - Month Day Year <br /> F 16.InternaAonal Shipments � � x - � ) <br /> LJ Import to U.S. <br /> nly): ❑ExportRom U.S. Pad of enlry/exit: <br /> = Transporter signature(for exports o <br /> W 17.Tr insporterAcknowledgment of Receipt of Materials Date leaving U.S.: <br /> Tra der l Printed/Typed Name <br /> a <br /> ' - Signature i <br /> rn ; ,O� Month Day Year <br /> y <br /> `- I / <br /> R <br /> Transporter2 Ptint d Name - - •" - <br /> �J Signature <br /> Month Da Year <br /> 18.Discrepanq i -- - 17 7 1 ) 7 <br /> 16a.Discrepancy Indication Space <br /> ❑ Quantity El Type El Residue <br /> OPaniel Rejection ❑Fall RejecOon <br /> 18b.Alternate Facility(or Generaor) Manifest Reference Number: <br /> d U.S.EPA ID Number <br /> LL Facility's Phone: .Y <br /> y�j 18c.Signature ofAltemate Facility(or Generator) <br /> = Month Day Year <br /> 19.Hazardous Wase Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator:Composition of receipt of hazardous materials covered by the manifest except as noted in Item l8a <br /> Pnntedayped Name - _ <br /> Signature y Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> _ i 14941/1560,2:3 DESIGNATED FArrILITY TO GENERATOR <br />