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PI <br />case print or type. <br />W <br />O <br />w <br />z <br />LU <br />a <br />UNIFORM HAZARDOUS 1 Generator 10 Number 2. Page 1 of 3. Emergency Response Phone <br />WASTE MANIFEST t U90j IM, i !.Ilse 4#�k� 3l. <br />5. Generator's Name and Mailing Address Generators Site Address {if different than <br />-kt3W .1A I Lt.) I li 143R %- li IW <br />1 �23 1tv (�Kqfl'M WAY <br />91 rX;K 1(A-4, CA OSM <br />Generators Phone j"16"862 <br />6. Transporter 1 Company Name <br />Form Approved, 0i No. 2050-0039 <br />ng Number <br />27049 JJK <br />�AWWAJIIF'?7W <br />7, Transporter 2 Company Name U.S. EPA ID Number <br />�1"JkLIL)W10t CAwk17°.4V2. <br />8, Designated Facility Name and Site Address f t U.S. EPA ID Number <br />O!?t.N! IJ8 1-16Hlilxv Oft ��f2 l3i ice+: t1�i5 <br />r kli Ar_' bM.)Ei'S <br />Facility's Phone:''f <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class. ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Ouantity Wt.lVol. <br />L <br />Qi 1 <br />Fk)WMF'}RlNA29414.Ii IAiAF,'ftr` t`C }i..4C?moi. $ t:#t , fmFyr-F.' sr r„o nt ;:r ... <br />3. <br />4. <br />r'i�a,11 tt.{ Er11 lFrbl._4I4f r:., r"'U'St-rKE;;t[J I <br />15. GENERATOR'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 intemationai and national governmental regulations. If export shipment and l am the Primary <br />Exporter, f certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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) (ifi am a small quantity generator) is true. <br />Generator'slOfferor's Printed/Typed Name Signature Month Day 1 <br />r y <br />-1 16. International Shipments <br />❑ Import to U.S. <br />Transporter signature (for exports only): <br />W 17. Transporter Acknowledgment of Receipt of Materials <br />UJ <br />Transporter 1 Printed(/Typpe/d�Name <br />Z Transporter 2 PrintedlTyped Name <br />❑ Export from U, S. Port of entrylexit: <br />Date leaving U.S,: <br />•� k <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />18b. Alternate Facility (or Generator) Manifest Reference Number. U.S. EPA ID Number <br />J_ <br />U <br />LL Facility's Phone: <br />w 18c. Signature of Ahemata Facility (or Generator) <br />Q Month Day Year <br />2 <br />pDesignated <br />Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systems) <br />2. 3. Notice: State of California requires <br />generator to photocopy and r ii to <br />Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item i8a DT5C with 30 days: <br />Signature <br />P.O Box 400 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete, Sacramento, CA 95812-0400 <br />GENERATOR'S INITIAL COPY <br />