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vynNr Form Ap ed.OMB No.2050-0039 <br /> Please print or type.(Form designed forum on elite 12-pitch)type <br /> UNIFORM HAZARDOUS 1.Generator ID Number .Pag3 <br /> e 1 of .Emegericy Response Phone <. (�nI((��I <br /> WASTE MANIFEST C.41000.2203 1 2 918:3'1 fila' V V umbX15 JJ K <br /> 5.Generatofs Name and Mailing Address Generator's 56e rens in different Manmalllng address) <br /> fAEPCO LABEL 91,9111 MS <br /> 29 W .SURI)PA ST - <br /> STOClRCrtl,Cf 95:192 <br /> Generators Phone::a)9.96dfYA1 U.S.EPAID Number <br /> 6.Transporter 1 Company Name <br /> F�•Iv105 F'FL Ik RNtl.IFHI:+L SERA rICE i,a IXiJdCk_1'sFf.+x <br /> 7.Tmapcta 2 CMPany Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Adore- RntlOS EN"1Fti1961FiJLh1. ;:ER`aCES U.S.EPA ID Number ,�fyr4•un: 15p. <br /> 1515 S.ffN.'ER RO-ll <br /> w25f SACR^blENffO,Go W. 91 <br /> 31d i71 51A7 <br /> Fad' a Phone: <br /> 9a. gb.U.S.DOT Description Wkgrg Pmpa Shipping Name,Hazard Class,ID Number, 10.Con"mare 11.Tool 12.Unit 13.Waste Cedes <br /> HM and Packing GreuP(d any)) No. Type WanNy WtNd. <br /> 1_ e_r � r.• a .�_ r._a ru..�� . st za 1 � n x <br /> K rc # c - <br /> 0 <br /> a <br /> z 2. <br /> 3. NOV I b Z# iZ <br /> a. EWRONMEN AL <br /> HEALTH DEPART ENT - <br /> 14.Special HandlrgWd <br /> Insions and Additional Information <br /> HANR)I JE GTO 8E 3P AINEO <br /> "ER' s:UN7rP,A/;TIrTi RAEdCi3 ENC 9R1)tgMEFR.1- fF' .i.f <br /> r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are Ntyand accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacsrded,and are In all respects In Proper condition for transport according to appImble International and national governments!regulations.If export shipment and I am the Primary <br /> Exporter,I ceNfy that the contents of this consignment conform to the tams of the attached EPA Acknowledgment of Consent. <br /> I cerdy that the waste minimization statement identified in 40 CFR 282.27(a)(8I am a large quantity generator)or(b)(41 am a small quantity generator)is true. <br /> GeneatcaVOlfemrs Pmdedlryped Name Signature Month Day Year <br /> j 16.International Shipment <br /> ❑Import to U.S. Export from U.S. Portofentry/ext <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter t Primedffyped Name Signature Month Dry Yea <br /> i <br /> a Transporter 2 Pdntedlfyped Name Signature Month Day Year <br /> r- <br /> ♦ 18.Discrepancy <br /> 18a,Disaepancy Indication Space ❑ Qonh, ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> U <br /> ser.. FaoTtys Phone: <br /> ala 1&.Signature ofAltemate FacifM(or Generator) Month Day Year <br /> Z <br /> H19.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 Fadiy Owner or Operator.Certification of recegt of hazardous matedals covered by the manifest emeptas Med In Item 18a <br /> 1 Pmtedlfyped Name Signature Month Day Year <br /> EPA Foran 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />