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,• i <br /> Please print or type, �111nM11111 Form Aproved.0M8 No.205(f-0039 <br /> UNIFORM K47ARDOU I 1 Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest racking Numbw 11 <br /> WASTE MANIFESTLI-LL 1001794195 VES <br /> 5.Ganerator's Name and Mailing Address YU12"GALVAN Generator's Site Address(If different than mailing address) <br /> FEDMIC(4 ROUND SAM <br /> SM EK=WAY <br /> a CA §=Am <br /> Gerhareto�s Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> E V1110M eS ALSoEVVIl" H a D 0 S 0 a 3 1 a a 9 <br /> 7.Transporter 2 Company Name US.EPA 10 Number <br /> E <br /> B.Designated Fatally Nara and Site Address U.S.EPAID Number <br /> 1125 BMOUYSn= <br /> Faar s Phone; XK26#0W CA 941 IC A T 0 8 0 0 1 4 0 7 9 <br /> 93. 9b.U.S.DOT Description(Inning Proper Shipping Nam,Hazard Class,ID Number, 10.Containers 1,.Total 12.Unit <br /> 13.Waste Codas <br /> HM and Pecking Group(IE any)) No. Type Quantity WWol. <br /> c x , UM175,WAWM saWS CONrA]NMFiANNAB18 FOW 332 <br /> h i��.,�Scoc1MTA�hre'�ow�i <br /> KLV*m41,1L 2 D F 1 8 2 F D001 <br /> Uj <br /> x 2, =711111% CONMoMEWPM 8A&.MOD= Doan <br /> 4 D F 839 P 112 <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions andAdditional Information 1R am CONN81W wVVXM + � � <br /> �w�i�IlW baYeRf�6MIM1i94M1�1IM1 1M1001111I11p1�1111111Mf�1EYiL + 11,1=213 lW:7184rA: <br /> 50 2)EW s4W-1Q2 WA:A=7UV=1S <br /> 15. OENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment aro fully and a=ralely described above by the proper shipping name,and are dasslfled,packaged, <br /> marked and IabakWplacarded,and are In all respects In proper oDndftion for transport aowrding to applicable fntemationa€and nations]govemmental regulations.If export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment oonform to the terms of the attached EPAAdmvaAedgment of Cuasent. <br /> I certify that the waste minimization statement IdentifW In 40 CFR 262.27(x)(d I am a large quantilygenerelor)or(b)(61 am a small quantity generator)Is true. <br /> General slOfieror's PriniedlTyped Name r Signa �} �}--}�1 Month Day Year <br /> W�oV -1 Vt10 All 812 1 <br /> 16.Intemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexdt <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W ials <br /> 17.TranspaderAcknowf4ment of Receipt of Mater <br /> LU <br /> a Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> � 1f 10 911 012 1 <br /> Transporter 2 Pdntedllypad Name Skinature Month Day Year <br /> 18.Discrepancy <br /> 18x.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejectors <br /> Manifest Reference Number <br /> F— 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> ti Facliityfs Phone; <br /> LL, 18c.Signature of Aftemate Fadtry(or neratar) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Repoli Management Method Codes(I.e.,codes forhazardous waste treabnent,disposal,and recycling systems) <br /> LU <br /> � 1 z 3. 4. <br /> 20.Designaled Facility Owner or Operator,Cedlilcadon of recefpt of hazardous maledals covered bythe manliest except as now In Item 18a <br /> Prinfedfryped Name,C Signature Month Day Year <br /> /-&-- �Q d 13 1/g 1 V <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />