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t Pleaue pt or type. 8; G L / <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> M,NA�NIFEST C A R 0 a 0 2 8 5 9 3 2 t BSS 541-3940 021985797 JJ K <br /> HeeNhGe-Lest Site�dd�res�(itdffe,�tthan mailing address) <br /> 49 S010 Van Noss dAV®SIM 9000 W Verralls Rd <br /> San Francisco CA 94103 Tmey CA X77 <br /> Ge one: 4,1 5 2 5 2 - 3 97 7 <br /> 6. nsorterlCompo a S.'EPAI Nu" F„". �"�" '� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Aff"M r w Site Address U.S.EPA ID Number <br /> 180 W.molts'Avenue <br /> [ dnk►gliOn CA 92316 <br /> Facility's Phone:9W 421'2(M2 C A D 9 8 2 4 4 4 4 8 1 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Totals 12.Unit 13.Waste Codes <br /> HM and Packing Group if any)) <br /> No. Type Quantity Wt.Nol. <br /> � 1 .n.a.s., ! •esr, n), i 343 <br /> o 10 C <br /> z 2 sty l <br /> W IgW ► 352 <br /> 3 Lill(Fosrtw ) U3 <br /> s p�-= s cz <br /> 4. <br /> c <br /> 14.S ecial Handling Instruct' andAdditional Information °Y1L/ c r LU- ,-e �r ae vt ra 2X5 I ' FROV N Vol 27779 <br /> 3}pF0' One or more of the ME.fetial listed on this may''' `. <br /> _57 <br /> He recycled as alterrult.!dady.cayec(AaGW attar- <br /> Mcthod which uses the material in or on the la .; K-O 2 t✓ <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 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 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)lift aim Amail quqk generator)is <br /> Geenferat('s/Oferoes Print rrype'd�"_"et' 0��2 Signature / Month Day Year <br /> 16.International Shipments <br /> I j,._ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> M 17.Transporter Acknowledgment of Repeipt of Materials t; <br /> w <br /> Tra�nnsporter 1 PrintedlTyped Name Signature + ` t 't 1."Mo 0r Day Year <br /> Cl?�%e� j r2 ( 1 . 6 1 �' 7b 126 <br /> Z Transporter 2 Prinl�dlryped Name Siglatuietr; ; = yMorth Day Year <br /> 18.Discrepancy l. <br /> 18a.Di pre pancylndication Space Quantity ❑Typ ❑Residue -�Pa 'I Rejection ❑Full Rejection <br /> b'u -. f �ra�ec c� h Mw •t /�_ c 5cNt A Gt•���11A / ,ny7vF F-ter / 1f <br /> i. Manifest Reference Number.'V.2-- . <br /> 18b.Alternate Facility(or Generator) Y r " U.S. 1l7Number" <br /> HAZMAT tS&I' <br /> < FaciIlly'sPhona: EPA#CAD982444481 <br /> RRIATE PERMIT (cc ) <br /> W 18c.Signature of Alternate Facility(or Gene Month Day Year <br /> z FOR AND WILL ACCEPT TNN; b'VASTE <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes a' nt,disposal,and recycling systems) <br /> co <br /> 0 1 2. 3. 4. <br /> 1 { `'i i I Lit e <br /> 20.Designated Facility Owner or Operator:Certification of re •pt othazardous aterials covered by the manifest except as noted in Item ` <br /> Printed ame �/�� Signature I Month Day Year <br /> � t-4 - <br /> EPA Form 8700-22(Rei 12.17) Previous editions are obs316fe-. DESIGNATED FACILITY TO GENERATOR <br />