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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20504)039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manlfest Tracking Number. <br /> WASTE MANIFEST FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> J01*4 WIN. s EV1.14SIA4 SWP!7(*1 Co <br /> - 5 (;0R0 A[X) ANY <br /> r<."WYI-014. CA 9SA'm <br /> Generators Phone:7j <br /> 6. ransporter 1 ompany ame U.S.EPA ID Number <br /> ?44%wie-t?l C.}Kmic:;A Tarirp(-ft 41:': �C_1tIA AGTENVI'C) �ycl r t>-fj?tl,`G f1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 30-1 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. 13.Waste Codes <br /> F2{'PA Ilrrj�r�irxt . L{'.s',la,I' lfatt'i:� lQ3 t I'.sgrari j <br /> 0 <br /> W , <br /> Z 2d rr; I��: �r+ir�t,•,li y;r.•9.i:psei, '; ,. # }, ' I I -I . 's. ae�r) <br /> 0 <br /> 3' f`r.r'.+, 6k. .r,I,t •e k` R ie a lee5il'1 § ei' 'i0i3SEHta ��°° <br /> i <br /> 1 <br /> 4. <br /> i <br /> r , <br /> r <br /> i <br /> 14.Special Handling Instructions and Additional Information "? r.Ct I`J17rit:?t' f`: c'k? I' <br /> t ('17020 <br /> Al <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: 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 intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified 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 /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> Z1:1 Import to U.S. E]Exportfrom U.S. Port of entrylexit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> OTranspo ter 1 P ntedlTyped Name Signature :` Month ay Year <br /> a. <br /> Cn <br /> I <br /> Transporter 2 Pdntedrfyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type ❑Residue E]Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> 0 <br /> Q <br /> u Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treabnent,disposal,and recycling systems) <br /> LLJ O t. 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 18a <br /> Printedriyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />