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9/71-1 1i11
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<br />Form A roved OMB No 2050-0010
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<br />UNIFORM HAZARDOUS 1. Generator ID Number . ,, i..- 1 7 0 .-.. ' : ri () 2. Page 1 of
<br />: ,, 3. Emergency Response Phone 4. Manifest Tracking Number
<br />WASTE MANIFEST ' .--b,, to- Z.(-)... 6,6.s. ..(-.0 .5"--6 -`?,1 r6 J22228314 JJK
<br />Generator's Name and Mailing Address Generators Site Address (if different than mailing address)
<br />JIA,1-'1,) -.. • ,. - LP 17 -1 120 r .1- 7 'CT ‘... 1-,,:;:i- -.4 ,-I (,:‘,..i
<br />I777 d• ilow11-0 9 les. 14 -rfri/z_d r 1 rex ?Lfio
<br />Generator's Phone:'. 5 K I: ---/ ti4 p-VA- p 0 /70 ef I ‘11S C* - I LA -f_ti K" p11 i rk ?s5S 56
<br />Transporter 1 Company Narita
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<br />U.S. EPA ID Number
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<br />Transporter 2 Company Name U.S. EPA ID Number
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<br />Designated Facility Name and'Site Address . . - .. . I tt, 9-661,4.07 U.S. EPA ID Number r A- .c. C- 114 r ,ti,•4•- -.Kr -r-rti-e-totAf-A • - - - • ,
<br />3525( oi' jK ,1114 E Pi). Vcrrtrr-4 A 4 C1 411 / / CA 73-7341' C 61-09,06i/k01) /
<br />Facility's Phone: 5S1 3 f,,,,_ irityi lit ‘ I ;
<br />ga. 9h. U.S. DOT Description (incluerng Proper Shipping Name, Hazard Class, ID Number. 10. Containers 11. Total 12. Unit v,i'asie 1. Codes Hm and Packing Group (if any)) No. Type Quantity 'Al. ivoi.
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<br />Special Handling InstructCns and Additiora; Information
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<br />GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents cf this consignment are fury and accurately described above by the proper shipping name, and are classified. packaged,
<br />.. markedead tabelectiplacazded, and are In. ail ITAPeas_ ifIXPel.02114itign fgliraesportapjording kapplicable intermatior.ial and national govornmentai regulations. If.export Ilitil,,,(1?nt and I am the Prirlia.i.Y
<br />Exporter. I certify that the contents of this-consignment tonfomfto the terms of the attached EPA Acknowledgment of Consent. i .. . . - .. .. . . - .... •
<br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if I arc a large quantity generator) or (b) (it) am a small quantity generator) is true.
<br />Generpor's'Offeror's Printed/Typed Sigt,:t, nth Day
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<br />Year
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<br />-S-. -- 16 International Shipebents 4i . N - ---% Port of entry/exit: Import to us. Export front U ( Transporter signature (for exports only): Date leaving U.S.:
<br />17, Transporter Acknowledgment of Receipt of Materials TRANSPORT! Transporter 1 Printed/Typed Name Signature .." / Month Day Year
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<br />11. I I 2 (11 2 1 ok i / i Z-e.) efi r? -/Z_ I ,' -%. - L. Transporter 2 PriMed/Typed Name Signature Month Day Year
<br />I , I I I I .4- DESIGNATED FACILITY -0- I 18. Discrepancy
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<br />Discrepancy Indication Space Quantity Type Li Residue Partial Rejection Full Rejection
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generate) Month Day Yen'
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal, and recycling systems)
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<br />29. Designated Facility Owner or Operator: Certifta ion of receipt of hazardous materials covered by Use manifest except as rtried in .Item 18a -.
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<br />Printed/TypedName SIgnature t Month Day Yea,
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<br />r.''). \-) C Yike6r-0144---- . I V.atii tLAIA13-14i1---- VII, I-? r: ,
<br />EPA Form 8700-22 (Rev. 12-17) Previous editior are obsolete. tl DESIGNATED FACILITY TO GENERATOR
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