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06 / 11 / 2021 1 : 46 Phi FAX 2099488625 ALICE SAW 0003 / 0007 <br /> Please print or type. Form Aoproved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number2. Page 1 of 3 Emer0eilcy Response Phone 4, Manifest Tracking Number <br /> WASTE MANIM$T G u F <br /> 5. Generator's Name and Melling Addross Generator's $Ile Address (if different than mailing add(ess) <br /> Generalor's Phow <br /> 6. Transporter 1 Company Nomo US, EPA ID Number <br /> 7 , Transporter 2 Company Name U.S, EPA ID Number <br /> 8. Designated Fadlily Namo and Sitc Address U , B, FPA ID Number <br /> FafAhiy's Plexi: <br /> qa gb. U.S. DDT Description (including Proper Shipping Name, Ha�arrt GL:u;9, ID Number. 19, Containers t t . 'felal 12. Unit 13. Waste f;ntlot <br /> HM anti Parking Group (it any)) No. Type Quantity Wt,N011 <br /> 1 , <br /> 0 <br /> til <br /> z 2. <br /> W <br /> fa <br /> 3. • <br /> I <br /> 4. <br /> 14, Special Handling InslntrdlOn6 and Additional Information <br /> 15 GENERATDR'S1bFFERQR'SCERTIFICATION: thereby declare that the contents of this Wnsignment are fully and accurately described shove Uy lite proper shipping name, and are classified, packaged, <br /> marked and labaledlplscarded, end arc in all respects In proper Condition for transport according t0 applicable international and national governmental regulations. If export shipment ant] l am Uro Primary <br /> Exporter, I cerliry Utut [tic contents of this cnngionmunl conform to the larmk of the ellachud EPAAcknowledgmeitl of Consent. <br /> 1 curdry that the waste nunimication statement identified to 49 CFR 282.27(a) (if I am a larr]o (ivanUly generator) or (h) (d1 sin it small quantity gsrismfor) is true. <br /> Generatorg0flurors Printed/Typed Name Signature Month Day YOar <br /> 16. Inloandionaf Shipments <br /> j. U EJ Import to U.S. L_ Export Irom U.S. Port of entry/r..xq: <br /> Tran?.porter ukinalure (for exports only) ; Date leaving U.S .: <br /> 1 r. 'nansporter Acknrnvledgmerd of Receipt of Materials <br /> Transporter 1 Printett(Typcd Name Signature Month Day Year <br /> Q ' <br /> Transporter 2 PtlnteUlTypad Name Signature <br /> MonUt Day Year <br /> 18. Discrepancy l <br /> j 188. Discrepancy Indication Space n Quantity Li type ❑ Residue I Parrot Rvioction ❑ Full Rejection <br /> c Maniresl Reference Numhsr: <br /> F� 18b. Alternate Far•.itity (or Generator) U . S . EPA IU Nvmbcr <br /> J <br /> 4 <br /> i r+ Hldlily'sPhone: <br /> 0L loo, Signalurc of Alternate Faclllty (pi Generator) Month I )r,y Year <br /> 19, Hazardous Wastu Report Management Willed Codes (he., codes for hazardous waste IraahYiviiI, disposal, and recyvling systems) <br /> Notice : State Of Cal +fornix requires <br /> generator to photocopy and mai ! to <br /> 20. Designated Facility Owner or Operator: CP.11if1(:at1un of receipt of Kwor(lous materials covered I)y the manifest except ou noted in Item 18, _ ; . <br /> Printect l yped Nuri SignatLl <br /> ure <br /> EPA Form 8700-22 (Rev. 12.17) Previous editions are obsolete . <br /> i' <br />