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Please print or type, Form Approved . OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 14 Generator ID Number 2 Par I of 3. Emergency Response Phone 4. Manfifest,}TraOl um r _ <br /> WASTE MANIFEST c ,A1 . Uttu ltlth i 1 }y ytr.S • ttir::` t 0 b � ; � � GBF <br /> 5. Genorator's Name and Mailing Address Generators Site Address (if different than mailing address) <br /> 1UEALk!:iEt,rIOUt*SIcr11Uli OCK <br /> 1*3r N , i.:A )( l + tJ6I AT f± ;,ate . Lt�t1ISF AVE <br /> I Ukt- it t. : I . : t A i) ;i;4tl(1 4 R( <br /> General o11Phon ' I ' l ' r t_ra'MitC)1' ( : A fi`d: 1 <br /> 6. Transporter i Compatry ame <br /> U,S. EPA ID Number <br /> Af it1CAAt VNLi . I: tStr"ytiytF ( tlt. , [Ni t .raltlar) "?. ltai.Et <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> s1 r ( t - t ' ' <br /> 8. Designated Facility Name and Site Address U .S. EPA ID Number <br /> IJiltl/► Yk !i l WAS 1E IttA4!+FL• tf inA(.q_! fY A: F�Oi.DD�2St4fi <br /> 0900 US htt(tr MXV DS <br /> V I )Wv. A; l ',•..14ife <br /> Facnit 'sPhone: rr) ; <br /> ga. 9b. U.S. DOT Descriplran (including Proper Shipping Name, Hazard Class, ID Nu 10 ontainers 11 . Total 12 . Unit 13, Waste Codes <br /> HM and Packing Group (if any)) <br /> No, Type Quantity Wtivol. <br /> 0 449)N- RC: RA I*SA / AH. ( K'AJF: WActirt-' kc (11 (�j AAf t0RHfW1 4 0II i ' It :ii_ • <br /> � . <br /> z 2 <br /> w <br /> CD <br /> 3 . <br /> 4, <br /> OCT 22220 <br /> 144 Special Handl ng nsuuct ons and Additional Int nna8on <br /> 1' kk)rlLl=� Ii3I15131%il i F'APE 19t.Tt_ I I_ HQi# Ill ENVIRONMENTAL HEALTH <br /> FMInF#�:i ` `YCt?I`itACT; At_ U{ PERMIT/ SERVICES <br /> 15 GENE TC <br /> EROR'S CERTIFICA : I hereby' declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, <br /> marked anlacarded, and are ail respects In proper condition for bansport accord ng to appl cable in emalional and net onal govemmanlai regulations, if export shipment and I am the Prmary <br /> Exporter, I the conten is consignment ccnfofm to the temw of the attached EPAAcknowledgmont of Consent. <br /> I certify thae ml don statement identified In 40 CFR 262.27(a) (if i am a large quantity generator) or (b) (it I am a small quantity generator) Is true. <br /> Generatoesl0fferor's PrntedrTyped Name Signature Month Day Year <br /> 16, International Shipments <br /> ❑ import to U.S, ❑ Export from U.S. Pont of entry/exit; <br /> Transporter signature (tor exports only): Dale leaving U.S.: <br /> W 17, Transporter Acknowledgment of Receipt of Materials <br /> Trans Iter, t Print ' } Month Day Year <br /> Fm , ypal Name S gnature <br /> p 1 t � ' t <br /> as <br /> z TrarspbrGr 2 PMI&dffyped Name Signature Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy indication Space ❑ Quantityype <br /> ❑ T ❑ Residue Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number, <br /> 18b. Allerrune Facility (or Generator) U.S. EPA 10 Number <br /> v <br /> LL Fau!ilys Phone: <br /> llk . Signature of Alternate Facility (or Generator) Month Day Year <br /> 19. Hazardous Waste Report Managemmnt Mo9W Codes (I.o. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 2 3 Notice : State of California requires <br /> generator to photocopy and mail to <br /> N Designated Faouty Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a DTSC with 30 days : <br /> PdribidiTyped Name Signature P . O Box 400 <br /> Sacramento, CA 95812. 0400 <br /> EPA Form 8700-22 (Rey, 12w17 ) Previous editions are obsolete. GENERATOR' S INITIAL COPY <br />