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psi :211335 .41 <br /> 5 .3 <br /> 41* 4 00~ 00HUMP <br /> Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of" 3. Emergency Res nse Phone 4. Manifest Tracking Number. <br /> A T. in n 61 A 4 � 11711 1 000 42 •x - 000 . 1'1. 1006802290 GBF <br /> WASTE MANIFEST <br /> 5. Generator's Name and a_il�nddr ss Generator's Site Address (if different than mailing address) <br /> SRS; AM533 <br /> L .5880 MKENIXY AsVE <br /> ATRRQerPr CA I •t r 2 <br /> Generetots Phorte: �Y� � 5 `;:� � � - • �,.� '�'� " <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> FRT 'i"A r '.- r"M.i''STAIf , r" I , FtAtT . f , 1X" IT Y , Q n f'@ 11 1 3 n f1 6 <br /> 7. Transporter 2 Company Name U.S. EPA ID Nummbbeer <br /> LO 6!5 Igo <br /> 8. Designated Facility Name and Sith Address U.S. EPA ID Number <br /> MRITAGE I:'iW.GR.ONMENI `frAl ,7�+.eR'ti ICE , 4LI; C A 2 D n R 17 n S 4 n °1' <br /> 4 E STOREY RD <br /> Facility's Phone: <br /> 9a, 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Pa�cldnngg {Group <br /> t(if <br /> yanyy)) buy {rye �y y �y y� No. Type Quantity WtN01. <br /> ••• L 'wl:ijiS1.C}C1. ri4Tit lfA .[ f..i :.f �• i �+�ZLY 01r. 5PzT ;F , 1"TRP�. 4EWI i us <br /> aoc) P <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> 4, <br /> 14. Special Handling Instructions and Additional Information <br /> 1) CIC _ + 2auch4tt� 4 T $ Dfr 211116 s � 1 Itil42 <br /> Como remmee N 1}=:tferateir writers atrerfC§ 3iignc 71 $ tri lmllaf rai'trcoder tff Wd r.rt' RiDL •71'' P ba0rotat 91iiY'tfi affl t& or 427r ions tmarr, <br /> 15. GENEitATOR'SfOFFEROR'S CERTIFICATiOW 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations, If export shipment and I am the Primary <br /> Exporter, l certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgmentof Conant <br /> I.cer.* that the waste minimization statement identified 1n 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> GeheratoeslOfferor's Printaffyped Name Signature Month Day Year <br /> �„ ► s 2a tri u4Z �.� 30 a <br /> 16. International Shipments <br /> F I ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br /> ? Transporter signature (for exports only): Date leaving U.S.; <br /> W 17, TransponerAcknowiedgment of Receipt of Materials <br /> Transporter 1 Pdntedfiyped Name Signature Month Day Year <br /> 12 <br /> je Transporter 2PdntedrNSignature Mo th Day Year <br /> Name <br /> 6 <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> Quantity ❑ Type ❑ Residue ❑ Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b. Altemate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> LL FacilitysPhone: <br /> LU 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2. 3. 4. <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> Prin!Naped Name Signa Month Day Year <br /> EPA Form 8700-22 (Rev. 12"17) Previous editions are obsolete. ATED FACILITY TO EPA's e.MANIFEST SYSTE <br />