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Plaacc nrintnrfvnP. <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. ui�--NERAE uwti ft 1 lAL t;U T <br />UNIFORM HAZARDOUS 1• Generator ID Number 2. Page # of <br />3. Emargency Response Phone <br />424-9300 <br />4. Manifest Tracking Number <br />WASTE MANIFEST C A i.. 0 0 0 4 6, 6 4 0 1 <br />(800) <br />5. Geneyrallo¢r's'yName Generators Site Address (if different than mailing address) <br />�)and <br />�yMalliingAdydretss t yy i4 y <br />! i'v1`'i1,+ 8 bi 6 F 6'llwF;. §� E.-$t.01,a',! 3.'� 5 tit"S <br />3460 €EAGLE , RAY <br />TPI,Wa i' -919304 <br />Gonerators Phone: 20 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />WORLD Olt. ENVIliONMENTAL SFRVICE0 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8, Designated Facility Name and Site Address U.S. FPA ID Number <br />U3, ECOLOGY VERNON INN <br />6316 SOUTH B YL AVENUE <br />� A�`SGE.. L S <br />I~WANGELES <br />Facility's Phone: (8400)26C-7747 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10, Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. NON- CRA WARDOUS WAS '!`E ;9C 1,110 (BRAKE MME SI-AVIN g) <br />0 <br />z <br />z. <br />LU <br />to <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information fi <br />EMERGENCY COUMT ' C! -(EW REO 1-80a424-9300 WOE S TERMt6NAL: CERE8 CoNAERG# M, : VA * PRO iLE # 9131, ; <br />T RAM -orf. THE BRAKE Lff HE SHAViNGS 1v P500-001,05106 ',: APPRI. PRIXfE PPE EQUIPMENT <br />15, GENERATOR'SfOFFEROR'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 Iabeledlplacarded, 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 />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAckpowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if f am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />GanoratorsfOfferoes Printed/Typed Name Signature,., ; Month Day Year <br />;r <br />f. <br />_j <br />Intefnational Shipments <br />Ll �f <br />Import to U.S. 1 ❑ Fxporl from U.S. Port of entrylexit: <br />9 <br />116, <br />Transporter signature (for exports only): Date leaving 6:S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />6R <br />Transporter I Printedfryped Name S'sgnature ,. Month Day Year <br />aTransporter <br />2 PdntedlTyped Name Signature Month Day Year <br />a <br />18. Discrepancy <br />18a. 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 />LL <br />Facility's Phone: <br />LLt <br />18c. Signature of Alternate Facility (or Generator) 1 <br />Month Day Year <br />co <br />19, hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLI <br />20. Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. ui�--NERAE uwti ft 1 lAL t;U T <br />