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i <br /> Please print or type.(Form designed for use on elite(12-pit'oh)•riter.) is <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 17,Ge�eretorlD�Jur(1�rer11 > �r Q "S ? r 2p Page i of Emergency Response Phone 4.Manifest T/rracking Number <br /> WASTE MANIFEST II Irv! ri�� �r�M1 OLis4 3955 JJK <br /> 5.Gen""Milo Ad(M ddress Generator's Site Address(N different than mailing address) <br /> Yit'7 CAARK DR <br /> c',1T)Ck'[ON RA 9Fi' C <br /> Generators Phone: 909#Q 1927 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ASR.JR <br /> Y FWRI� *w+F_NTAL RFRMCFB r A F1 n R ;' '7 7 0 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desigpaled Eaulity.War�eandSitaAddress U.S.EPA ID Number <br /> M N ALAKDA F I RIT I <br /> C,W. ItN6 t:A W272 <br /> t3ifiyr,Tr-71nn ti A r >J li w D i j r; <br /> Faciliys Phone: <br /> 9a, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> o hb)N-RCRA IIAZZART"r,III TF 1,VY gD Wiliti IT1,N01 <br /> . D M <br /> w <br /> Z 2. <br /> co <br /> 3. <br /> 4. <br /> 14.Special Hand``lin�g Instructions and Additional Information <br /> NAEfar`2(*i 171 °PRCrF11 F#901 2 Fr7 J Fit Ah1E f1.I IIt)'Pry q 1 if1€17961 'A,PPROPn1ATE PFR':C+K PROTI CTI <br /> F0111PW-NT <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplaarded,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,I certify that the contents of this consignment coMotm to the tens of the aaached EPAAcknowledgment of Consent. <br /> I arMy that the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)if I am a small quantity generator)is true. <br /> GeneratoesrORerors PrinteifTyped Name Signature Month Day Year <br /> 16:International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pon of entrylexit: <br /> Transporter signature(for exports only(: Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> y Transporter 1 PmdedNTyf)ed Name �. Signature Month Day Year <br /> C <br /> QTransporter 2 PdntedRy6ed Name Signature Month Day Year <br /> K <br /> I <br /> 18.Discrepancy18a.Discrepancy Indication Space ,❑ Quart ❑Type ResiduePartial Rejection Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> CD <br /> 19.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 iso <br /> Pdntedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />