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Form Approved.OMB No.20SH039 <br /> e.(Form designed for use on elite(12-pitch)typewriter.) :.� 4.Manifest Tract NumMr <br /> 1.Geneamr ID Number 2.P- 1 of 3.Eme Response,Phone 9 <br /> A HAZARDOUS ;._t ii 0<'6 3 3 7 1 �9?21m/Ul 4,:4_3t1(: 1� 51 a 3 JJ K <br /> ,TE MANIFEST <br /> merob{f.�(?rPg P14 ypswg{1Adress GeneraWrs Site Axldresa CddiBerent than mailing address) <br /> Generators Phone: U.S.EPtIg hiumin,B,y -, ?c a E <br /> fi.Transpor�ei �iPsnrY ? aNMEN(AL SERVII 5 <br /> U.S.EPA IO Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA IO Number <br /> 8.Design f01t6�(�e zS)�e.Pdf r�syIN. LIC. <br /> 1428 t EA-ST MANNING AVENUE t'A 1, 0(0 0 2 / °, 1 <br /> rARLIEF7 CA 4.,648 <br /> 15Pi r14W0240 <br /> Faciliys Phone: <br /> 9b.U.S.DOT Desorptionme,Hamel Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No. Type Quantity WWoI. <br /> HM oho Packing Groany)) _ <br /> r ni, .a•Nru lu:+,r.r.n,_•a. + <br /> J <br /> Z 2. <br /> W <br /> (7 <br /> 3. <br /> 4. _. <br /> 14.Spedal HandN imiwcWm aho AddnlmallMormatim r - cflr l�GEl+it:i <br /> f.fvfEF'G(-NC�1;PNTATT "'t'TRF.0 9 f3Ot1.424-9300`APPf?ltpRlAiE !'ER"aONAL.PRC+f El:.11'i. Er1UIP8h{.I-•:t <br /> -i,r ,;;� :it ;i5fn�42d-�)_'•CXl ' ._a.i- r , <br /> 15. GENERATOR•SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment arefulty and aauralely described above by the propershipping name,and are classified,packaged, <br /> marked anrd labeledlpiaceided,and are in all respeds in proper conation for transport according to applicobrg mtsma8anal and national governmental reputations.N export shipment and i am the Primary <br /> Exporear,ytcedify that me o,nlots of this consignment cantafm to the teras of Bre aearhed EPAAdmwAedgm�ssentof Consent. <br /> I cerffy mac thew,,te minimiution statement identified in 40 CFR 28227(a)(d I am a large quantity generatorAa(b);(dl am a small quart gene r is bus. ear <br /> Signature <br /> Genera 910lferers P7rinted77y Name <br /> \.i <br /> � i6.IntemaJ nelShipments ' ❑Import to U.S. ❑Export from U.S. Pon of entrylexit _ <br /> t— --Date leaving U.S.: <br /> Transporter signaWre(for exports only): <br /> W 17.TransporterF <br /> t of Receipt of Materials <br /> ' Tramporterl Pe.. !; ' ! Signature r <br /> Mordh -Year <br /> c Day Year <br /> GTransporter 2 PmeSignatureC <br /> 18.Disaepanc18a.Discrepanace ❑ puandry ❑Type ❑Residue ❑Partial Read. ❑Full Rejector <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> F 10b.Alternate Fadlity(or Generator) <br /> J <br /> f..l <br /> LL Fadltys Phone: Monro Day Year <br /> W ted.Signature ofAltamata FaclBry(or Generetort <br /> z <br /> H 19.Hazardous Waste Report Management Method Codes fie.,modes for harardous waste treatment tlisposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Fadltry Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a onm Day Year <br /> 1 PdnteMyped Name Signature <br /> F, <br /> GENERATOR'S INITIAL COF <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />