|
Please print or type. Form Approved. OMB No. 2050-0039 G ENE RAT 0 R I UNIFORM HAZARDOUS 1. Generator ID Number
<br />,. • .44 ;" • ,'• t., J4 i., .el 4 _64j „t.-: •fr. _ WASTE MANIFEST
<br />2. Page 1 of 3. Emergency Response Phone
<br />..
<br />4. Manifest Tracking Number
<br />0 JJK
<br />...k. sik ..e L.. ..i• ti
<br />5. Generator's Name and Mali g Address Generator's Site Address (if different than mailing address)
<br />Generator's Phone.
<br />6 Transporter 1 Company Name U.S, EPA ID Number
<br />,.`,4* : i N1 )1 ni4 1 Nii to CA 1..,0i, 20 QS lff'or<IW I
<br />7, Transporter 2 Company Name U.S. EPA ID Number
<br />I_
<br />8. Designated Facility Name and Site Address U.S EPA ID Number
<br />LA:irlt.," ftANICir/e..) i...4.,104 R 41,P), t. L f i
<br />'1•1**3 V.4414'i!. 1-15A.,a. Kt :A,,:
<br />%',''+..:1-4i 0 1 '4 ki1.4(1 ( !Iil (.1/,`, Pr,.
<br />Facility's Phone: ...., 0. etir4 AAR" I ". ' -.- ^ - 1 •
<br />ga. 9b. U.S. DOT.D.escdption (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes Ai and Packing Group (if any)) No. Type Quantity Wt.Nol.
<br />1. m ii4 i4...":4A H ig V Atii304.4 Aft 0 , 64)i_ii) (4tiutiiDEu , , -2-44:-- - 1.!? wi I eh ).40';(0.F Il tiViT1-4 ON . OfFfts="1 MI kcrtf.44411INMI
<br />'-.111 r,
<br />2.
<br />I
<br />14 Special Handling Instructions and Additional Information
<br />t. 1 6-) N 1.11.-4)41t)t1 -.ALI t 6
<br />t) 49:i,0111bilWaRif.i CataT4.041MA1t1) WiTM OIL, UWARIS AMP XtRCAVTAM LX55
<br />15 pENERATOR'S/OFFEROR'S CERTIFICATION: 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 />;larked and labeled/placarded, and are in all respects In proper condition for transport according to applicable International mid i wilts idl yuveliiiiitintal regulultui is. If expo' t bi lip i mil and I am the Primal y
<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) (if I am a small quantity generator) is hue.
<br />Generator's/Offeroes Printed/Typed Name SIflUf8 -.- Month Day Year ...-
<br />I =,..4,- :-., ; 1 .--' , I r% I t
<br />_.J
<br />1.-.
<br />16. International Shipments Import to U.S. U Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only) Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of hlatenals
<br />Transporter 1 PrIntedITyped Name Signature Month Day Year
<br />I 1 ,•:, 1 .., 1.
<br />Transporter 2 Printed/Typed Name Signature Monet • Day - Yedr
<br />I I I I DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy indication Space LII Quantity Type LI Residue Partial Rejection Full Rejection
<br />Manifest Reference Number.
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Day
<br />I
<br />Year
<br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, dis osal, and recycling systems)
<br />1. 2. 3. 4
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted In Item 18a
<br />Printed/Typed Name Signature Month Day Year
<br />I I 1 I
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY
|