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Please print or type. (Form designed for use on elite (12-Ditchr ,yoewriter.) <br />I:— A......,.....1 t%RAD kr.. nncn Anon <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />GENLeRATOR'$ WiTI.AL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />, (11e(t: 1�+3C'I <br />j <br />0100- d. If <br />5,4837 G B F <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Generator's Phone:20Q-,401.Olf1) <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />': Nc'cl�` �i.'{tsi;;� � �I.,s t't i+:+f4.�i. ►ll;;. �a •;i_; t(ltii�'If��tti�`- <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address t,� f -t `= {,-l�t i U.S. EPA ID Number <br />iIO'A55 il-f <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />oi <br />1. <br />a <br />i <br />LLJr— <br />z <br />2. <br />LU <br />0 <br />3. <br />4 <br />14. Special Handling Instructions and Additional Information <br />!.i.AY,ih�', �" ':�..�:il ifilt;; (��i.;#�9l�' F=}}.l'►�.!*?I�. )•k��'�L�:� � l:%lil't�j <br />,.;u <br />.rr'('tdat! � },tt11-t•Iltls'1 <br />15. GENERATOR'S/OFFERORS 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 labelediplacarded, 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) (if I am a small quantity generator) is true. <br />Printed/Typed Name Signature Month Day Year <br />_[7eneratoes/Offerors <br />l: i \ ;; i i si �t \, 1. � : '�Y �, ell11 ..5., dn' ; .`. F Ham'" s • y . <.+f a <br />r— <br />Ill 6sTnt�Ntidnat,Ship*ntb. a, c A } �— ,Y t, pp ; f ` ' ' 1 ;: ''• ' E'{•:. <br />❑ Import to U.S. Export from U.S. Port of entry exit: i <br />z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LI <br />17. TransporterAcknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature d r Month Day Year <br />CL <br />Q <br />I <br />Transporter 2 Printe padNamel z' { Signature `w +` „�X w . Motilft" <br />H <br />1 B. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number. <br />jft Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />W <br />18c. Signature of Altemate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. 2. 3. Notice: New federal form. State of <br />California requires generator to photocopy <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and mail to DTSC within 30 days: <br />Printedrryped Name signature P.O. Box 400, Sacramento, CA 95$12-0400 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />GENLeRATOR'$ WiTI.AL COPY <br />