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Please print ortygal Form ADnved.OMB No.2050=0039 <br /> UNIFORM RAI,ARDOWS 1,generator ID Number 2.Page 1.of 3.Emargenoy Response Phone 4.4s-M5 Treg_Ing ftym* <br /> WASTE MANIFEST �`kt mst; < 4 1 fl . t t �:. c 3 �� JJ K <br /> 8.Generals s Name and Marling Address Canarator sSiteAddress Of dffrerentthan mailing ). <br /> QL a°)tAki-zAl <br /> Gene tDeS p <br /> 8.Transporter 1'Company Nama U.S.EPA ID Number <br /> mit-N 11 1�� t( - �� .� f.;i I(, i).ft; e• � t € <br /> 7.Transporter 2 Company tame 4p p g p${ U.S.EPA ID Number <br /> 8.Designated Fad Name and Slte Address U.S.EPA ID Numb <br /> 9a 9b.U,S,DOT Dese odw(indtrtlirrg Proper Shippng Name,Hazard Class,ID Number; 10.Confahiers 11.Total 12.Unit 13.Waste Codes <br /> Hit and Padding Group(d any)) No. TYVeCliiar lily WtJVdI. <br /> _. <br /> 12 <br /> O.' 1 WIN1`)y;1 tT co, . # Owl 3115 <br /> y��ar:1,l tt'1 I:161 <br /> LU 2. <br /> LU <br /> 3. <br /> 4 ,. <br /> 4„Special Brg Instrt+dlions and` Ovral Inforina8on <br /> 15, QEN—W' %'0FFMR'&GEM,I—WArK)f t.I hereby dedara that tha tests of poMptnent gre'fikty and a=ra*described above by the proper shipping Iterhe,am are dassiAe 1,PO&A, <br /> ;marked apd labeled/plaqrded;aqd are n all respects in proper condition for transport aoodrding to aWkable ntema**O send had"govemrrrental regulations;ff'export shipmentand I am the Primary <br /> Exporter,)oerW that,th oonter of tto, igturrent oonform tq th a terms of the attad►ed EPAAdmowledginsot otCortsetit. . <br /> I oerliCy Ifret the waste niinkotzatlon statement kierr6fied in 40 CFR X62 27(a)(if i am a law,qua"9eneratpr)or(b)(if I:amt.a srmcil quantlty generator)Is true. <br /> Generatot's/Oger ,'nWTYPed Name Month Day IYear <br /> IVI <br /> 16.In 3tdpmevtts "" r—� <br /> import to U.S. I_1 Export from U.S. Port'of enby/exit <br /> Trend signaw(for oxports op! ):_ Date issuing U.S.: <br /> AW <br /> 17.Ta rrs vWAcdgrowledgn"t of Receipt of MOONs,.Uj <br /> ra, rarispor ri Name " ` 5ignetlue Month Da Year, <br /> ITransporter?Prirrted/Typed Name Signature Month Day Year <br /> r,- <br /> I&Discrepancy <br /> 18a..Dwrepancy indicatlon Space ❑ Qty Q Type ❑Residue ❑Parris)Re)edion Dull Re)ection <br /> Manffest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> W Faciiffys Phare::.. <br /> W 1 Signature Ntsmate Fadlity(or Generator) <br /> a Monthr . Day Year <br /> 19.Hazardous We*Report Management Meow Codes(i.e.,codes for hazardous waste treaknent,disposal,and recydng systems) <br /> o 2- 3• Notice: State of California requires <br /> - generator to photocopy and mail to <br /> 20,Designated Fadillty owner or Operator.Certiflcatfon ot recelpt of hazardous materials covered by the manifest except as ncted in Item 18a ®TSC With 30 days: <br /> Printed/Typed Name Signature <br /> Q.a Box 400 <br /> aeiramento,CA 95812-0400 <br /> EPA Form 8700-22(Rev.12-17) Previous etlitions'are obsofefe. S <br /> ut NeKATORIS INITIAL COPY <br />