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Please ørint or tvoe. Form Approved. OMB No, 2050-0039 GENERATOR 4 . . ..
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Gentrator ID Number . :, 2. 9 0 g f tf,?r, 1
<br />C-74491441.1aZ
<br />2. Page 1 of 3. Emergency Response Phone
<br />%'00 c(-1 - 9O9 :'-'
<br />4. Manifest Tracking Number ..
<br />022228315 JJK
<br />Generator's Name apd Ma.iingAddress _ , Generator's Site Address (if differeat than mailing address) i
<br />'17*,efii 7 car-rt-e;ry-- Z/4 274//(0/0 +0444:174744_4 - 7 -las
<br />/64 /1 .1.• ',lc; d pi. IA 74ear; (4 9 c j-i'd
<br />Generator's Phone: cif , e t--y itixi v4 A-0 (log) Vst - Z$3 I IA 76/ea p / (,.4 q....rff 0
<br />Transporter 1 Company Name ' U.S. EPA ID Number
<br />(\lArilt,..1-3 -r -guc•hwt 1 cAiK000 ISY7 Y'
<br />Transporter 2 Company Name U.S. EPA ID Number
<br />. I
<br />Designated Facility Name and Slte Address . . i •. i / ._....._ % 44, 1,,, U.S. EPA ID Number
<br />r /4 IA (.; C. AA e -1,-- 7 l,:-.(-'-r7Y , Aniti/i
<br />.4.. 7 r, at9 kleY I Al '. R P. Ke- r-r1.-eAdorui Cliy, CA c-A /
<br />Facility's Phone: Phone: -S-9. " .2)g.C3- (ill I I
<br />go. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11. Total 12. licit 13. Waste Codes
<br />Fm4 and Packing Group (if any)) No. Type ()natty ',./1.:\io•
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<br />Iwo/ f<'cA ri 14 A 7-4 , e ci yktI W Ai re (SO/ i (IP)
<br />((i9 J(7 t I C./ CAP v p )
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<br />14. Special Handling Instructions and Additional Information
<br />(1.1. ko 7 (7, 0 (-., r 44- W./ / 6.• 4-
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<br />1.44(td II A Ncil iiv 6 111 15 7565 4/ ,
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<br />15 GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged,
<br />marked and labelectplacarded. and are in all respects in proper condition foqransport according to applicable international and national governmental regulations. If export shipment and I am the Primary
<br />-Expbrtefll oddity that the bontellt of MN cOrtsignment -cbriforM°to the tens 5t the attached EPAAcknowledgrnent of Consent r- - - • • - - • - • - • • - • • -
<br />I certify that the waste minimization statement identified in 41) CFR 262,27(a) (if I am a large quantity generator) or . 'r i a small quantity generator) is true.
<br />Gerlegitor'slOfferoes PrintediTypedltrame Signatu Month ...- -.
<br />-- ' r fr,---i.../ )vittiA--(242e, L,.. I .00::, , 4 Mii0
<br /> Day Year
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<br />16. International Shf(ments E Export from U.S. • . of entry/exit Import to U.S.
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER I I .- 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed lyme Signature Month Day Year
<br />7705 C C. i.....c).)-(,/;‘,.', 1'4 ,, I
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<br />I 612912/
<br />Transporter 2 Printed/Typed Name Si9n410 Month Day Year
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<br />18. Discrepancy
<br />Discrepancy Indication Space Quantity Type D Residue LI Partial Rejector. NH Rejection
<br />Manifest Reference Number:
<br />aILI-
<br />Alternate Facility (or Generator) U S. EPA ID Number
<br />Facility's Phone:
<br />2
<br />Signature of Alternate Facility or Generator) Month Day Year
<br />I 1
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1.
<br />:7
<br />-
<br />2. 3. 4.
<br />• 20. Designated Facility Owner or Operator: Cent/tics ion of receipt of hazardous materials covered by the manifest except as nded in Item 18a -
<br />
<br />Printed/Typed Name ,,.
<br />'11-4k V.,' 1
<br />. Month Day_ Year i i
<br />Arv,r131(tAL-----1
<br />Signature
<br />I \(iittA /Jill/114 I L'),9I 2-') I I - ____, . ,...e.,..... A Ton rAf".II ITV 'TA fICIJCDATAC
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions ate obsolete.
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