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Please print or type. (Form designed for use on elite ( 12-pitch) typewriter, ) Form Approved . OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generalor ID Number 2 Page 1 of . Emer envy Response Phone 14. Manifest Tracking Number <br /> WASTE MANIFEST C4L CVv,38q9g ���� 003740913 G B F <br /> 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> S'Is- I SAN �(�LI6'G $P- STS 1cWL� W Wu15L�7 A\) C <br /> MANTIJF Q Ar r"A `us33 <br /> Generator's Phone: }� �- � A ._7& `j <br /> r, 6. Transporter 1 Company Name U .S. EPA ID Number <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> S. Designated Facility Nam d Site Address U.S. EPA ID Number <br /> ZI s Cc�� e / c-M 1 <br /> C r1 / / <br /> im <br /> 0 k if J. IV \f ��� �rG 7� '� ' r - z � tr �J V�—1 �U� -/ S 4 <br /> i escription (including Proper Shipping Name, Hazard Class, ID Number, 10 . Containers 11 . Total 12 . Unit 13. Waste Codes <br /> oup (d any)) No. Type Quantity WtNol . <br /> oc�� <br /> Z 2LLI . <br /> 3. <br /> Q E <br /> 0 <br /> U <br /> N 4 . <br /> N <br /> O <br /> E <br /> E <br /> 14 . Special Handling InsWcfions and Additional Information <br /> IJci ,.3eCrL'1 - C71 <br /> 3 <br /> s0 <br /> 0 <br /> 15. GENERA TOR'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 transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> 2 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowled rent of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity genera r) or (b) (if I am a small quantity generator) is We. <br /> j Genetor'slOffer r' Prinled/Typed Name Q� C C� Signal a f,logtq y Year <br /> t 1 V 1 47 <br /> j 16. International Shipments <br /> H L1 Import to U.S. Ex ort m U.S Port of en lex t: <br /> p try <br /> z Transporter signature (for exports only): Dale leaving U .S.: <br /> R w 17. Transpo terAcknow1edgment of Receipt of Materials <br /> Tran orter 1 Pr nted yp d Name Si Month Day Year <br /> CL <br /> � „J z-t • _ 2 �- (9 <br /> R z Transporter 2 Pr ed/Typed Name Si alure Month Day Yea <br /> Q <br /> 18. Discrepancy <br /> h I18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b . Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day <br /> a <br /> Z <br /> 55 19, Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> Q 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 /> Pdnled/Typed Name Signature Month Day <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete . <br /> DESIGNATED FACILITY TO DESTINATION STATE (IF REQUII <br />