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Please pant or type. Foal Approved.0 M 6 No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID NUMbe 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �/ <br /> WASTE MANIFEST JJ n <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if diffefent than maeliog address) <br /> Generators PhQm <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.TranspofEer 2 Company Name U.S.EPA ID Number <br /> S Designated Fadliby Name and SrreAdd ress it S.EPA ID Number <br /> Fadslrty's Phone: <br /> 9:, 9b U.S.DOT Descdptroi(indludmg Proper Shipping Name,Hazard Class.ID Number. 10,Containers 11 Total 12 Unit t3_Waste Codes <br /> Hf.1 and Packing Group(it arty)I No. Type Quantity Wt.No' <br /> 1 <br /> Q' . <br /> o — - <br /> F <br /> NW <br /> W <br /> W <br /> a <br /> 4 <br /> 14 Special Handling s.^siructror:s and Additional Information <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the ronisnLs of this omsignmen',are fully and accurately described above by the proper shipping name,and are classified,pea aged. <br /> marked and Iabeledrplacarded,and are in all respects in proper condition for transport according to appiicable irrtemabonaland nafionak governmental regulations.If export shipmenl and I am the Primary <br /> Exporter,I cerbfy that the contents of this consignment conform to the terns of the aftadhed EPA Acknowledgment of Cormft <br /> certify that the.waste minimization statement sdentifled rn 40 CFR 262.27(a){if I am a large quantity generator)or(b)I;it am a.small quantity generator)is true: <br /> Generat&s,ONeror's Pnntsd,Typed Name Signature Ndcomth Day 1'.=9• <br /> '6 International Shipments <br /> ❑import to V S. ❑Export from U.S. Pcrt of entryiexlt: <br /> ? Transporter signature(for exports only}. Date leaving U.S <br /> 17.Trarsporter Ad aiow"rneMol Receipt of Materials <br /> 14,11 <br /> TransWer i PnntedlTyped Nam. Signature M" pay Year <br /> 0 <br /> CL <br /> in Transco to 2 PnnieOyped Name Srgriature Month Day Yoar <br /> tt@� <br /> 1.�.Dlscrepamy <br /> 180 Discrepancy Indicators Space ❑ Quantity ❑Type ❑ResiduePartial Rejection <br /> ❑ i-Full Reiectlu^ <br /> Manifest Reference Number <br /> F 18b Alternate Facility(or Generator) U.S EPA ID Number <br /> U <br /> LL- FaOKY's Phone. <br /> W -T 18d Signature VAltemate Facility(or Generator) Month Day Year <br /> d <br /> 2 <br /> '9 Hazardous Waste Report.Manageirient Mahal Cordes di.a.codes for hazafdcus waste heatment,dkspasal,and recycling systemsi <br /> © 1 3 Nflti -e: State Of California requires <br /> generator to photocopy and mail to <br /> 2C.tree gnawed Facility Owner or Operator:Certification of recsipd of hazardous mater.als covered by Me manifest except as noted Ir.Item i DISC with 30 days: <br /> RrintedTypedName amore P-p Box 400 <br /> Sacramento, CA 95812-0400 <br /> EPA Form 8700-22(Rev 12-17) Previous editions are oh5oiete. Ut_NtKA t Vet o urd i ip+a. ,OPY <br />