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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 115482201 <br /> fest Tracking Number <br /> WASTE MANIFEST � ob JA-1 A moo Gut -it 16 JJ K <br /> 5.Generator's Name and <br /> Mailing <br /> U ng Address TP.." -� "►f 5T C Generator's Site Ac�ss 4i.f difterent than marlin address <br /> Qrovh ! .c>f'te t S s n 4—cauy 9 ) Y <br /> Generators Phone: 2 Irl;cy CA Q53 77 <br /> 6.Transporter 1 Company Name U.S.EPA IQ Number <br /> P pb 'C vw.rv. Se sic CNS(i `6 7q <br /> T.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Nameand Site Address t r.ik O, U.S.EPA ID Number <br /> a3oo G1ays CA <br /> Facility's Phone: ZtaJ �((x,I CAA U� �U lC <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containe_rs 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> � <br /> z z. <br /> w <br /> 3. <br /> 4, <br /> 14.Special Handlfng Instructions and Additional Information <br /> 15. GENERATOR'SfOFFEROR'S 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 labeledlplaearded,and are in all respects in proper condifion fortransport 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 Conssnt. <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 /> Gan oto 10 P'ntedt y ed arae Sig ur Month Day Year <br /> +f �( L'!A <br /> 1 T ZZ� 16.Internation, Shipments <br /> V <br /> � ❑Import to U.S. ❑Expert from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> 17.Transporter Acknowfedgment of Receipt of Materials <br /> LJJ <br /> Transporter 1 Printedfryped blame <br /> E � Signa ^ M Day Year <br /> pay u-c� f�r�1 5 Zz <br /> zQ Transporter 2 Printedffyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility <br /> Reference Number. <br /> €y(or Generator) U.S.EPA ID Number <br /> V <br /> u. facility's Phone: <br /> 16c.Signature afAltemate Facility(or Generator) Month Day Year <br /> B <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ A f' 2• 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Prinledityped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. pit <br />