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# C A <br /> Please pr nt or type '' ' Form Approve ;OMB No.2050 OQ39, <br /> 4.1;ener.qr„#R Number' Q Page 1.,of 3 Emergency Response Phone 4 MgnifestTraokingg Number <br /> UNIF�HMP'HATARDOUS •..x,” '� <br /> 11�AS CB NIAtyI�1. �'A I� �. 0 0 � � � �..,� 1 '� -519,58- <br /> JJK <br /> 5.Generator's Name.and Mailing Address Generator's Site Address(if different than mailing-address) <br /> CCW > of PUM HMR11 1 "ReabMid Faces. <br /> 1 3W Mill St M 2111 W.1/BII7Oft Rd <br /> San Frank► CA 9'4102 TkaCy° CA 9W7 <br /> Generator's Phone: 4 1:'$ 2 5 ` 3 9 <br /> 6.Transporter Company Name U.S.EPA ID Number <br /> Etsvilllonlawntei Latgbifiz,Inc. �C A R o ID 0 2 1 7 5 1 .3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> i <br /> 8.Designated Facility Name and'SlteAddress "'1` U.S:EPA D Number <br /> ("60VW <br /> u'1eam ti <br /> Kates Oky MO 64129. <br /> Facility's Phone: 8113 924. M 0 D 9 g <br /> ga, 9b:U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes . <br /> HM and'Packing Group(if.any)) No. Type Quantity Wt.Nol. <br /> 1 <br /> X <br /> _7. <br /> 2. LOW <br /> 7A_14 <br /> N,l 41,7 <br /> Lu <br /> 0 <br /> wr <br /> AS <br /> 3: <br /> I <br /> 14.Special rHandling Instructions and Additional Information <br /> 64 5m �k A) <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,Ord are classed,packaged; . <br /> marked and•labeledlplacarded,and are in,all:respects,in proper condition.for transport according to applicable interpational and,natiogal govemmental regulations.If export shipment and i am the Primary <br /> Exporter,I certify tha[the'conhe'nts of'this consignment conform to the terms of the'attached EPAAckn6wledgment of Consent: ' <br /> I certify that the aste " mi tion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)("dl am a small q riti generator)is true. <br /> [Generator'sMLnt ,,pelame Ila 1Signature Month .Day Year <br /> 1 Z4 114 1 <br /> 16.International Shipments or <br /> ❑Import to U.S. ❑Export from U.S: Port of:entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter! Signature Month Day Year <br /> Ofo <br /> a <br /> QTranspo er ed(Typed Name. SignatureWo—nth' Day ear <br /> H J <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> D Quantity'. O'Type' ❑Residue ; D Partial;Rejection O Fvll Rejection <br /> :.Mand6st'Reference•,Number <br /> 18b.Alternate Facility(or Generator)i U:S EPP.ID Number <br /> -..J e... <br /> LL Facility's Phone: ti- <br /> w 18c.Signature of Alternate Facility(or Generator) Montti Day Year <br /> Q <br /> ;z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal;and recycling systems) <br /> 0 1. E <br /> 3. 4. <br /> ii I <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered.by the manifest except as noted in Item 18a <br /> PrinteVryped Name -, Sign a4re -��'� Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. - 1 DESIGNATED FACIL TO GENE T R <br />