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Please print or iForm deslcned for use or elite(12-pitch)typewriter.( Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Generator ID Numbe' 2 Pal 1 0l 3 Emergency Response Phone 4.Manifest Tracking Number G B F <br /> WASTE MANIFEST <br /> i G...mtors Name and Mau ug Address General Site Address(if different than riddling aodre<.si <br /> I <br /> Generators Phone' <br /> 6.Transporter I Comi Na ne J S.EPA ID Numxr <br /> 7 Transporter 2-ompany Nane US EPA 0 Ncmher <br /> 9.Desgrated Facility Name and Site Address V S EPA c Number <br /> Fact:ys Prore <br /> ga cu U.S DOT Desmodi including Prcper 3hloping Name.Hazard Class.ID Number 10 Containers '1 Total 12 unit <br /> '3 :caste Cores <br /> Nit z^tl Pacelrg Group p'anyll Na Type Quantify '.h^,.Vo. <br /> rY <br /> aO <br /> C <br /> w <br /> z <br /> w <br /> LI <br /> 7 <br /> 4 <br /> 14 Spada Hand,ing instructions and Additional Information <br /> GENERATORS:OFFEROR'S CERTIFICATION: I hereby declare that the contents or this cons gnmem are fully and accurately eescdbet above by the proper srnppmg name and are eabs6ee packager <br /> marredarr:abcledrpacamed and are in all respebte in proper condition for transport accordinc to applicable international and national governmental regulaicns Ifexporshipmerlandlamme Prmar; <br /> Exporter i'i that the contents of this consignment comonn to the terms of the attached EPAAcknewLedgment of Consent. <br /> erlil the the'.vaste minimization statement identified In 40 CFR 262.2T(3)(d I am a large quantity genaratoq or(b)ill am a small quartry generabri 6 true <br /> Genemto's'Otfe'ofs Printed'Typed Name Sigratpre Month Day "ear <br /> J 'E.Irterrarional Shipments <br /> H ❑Import to U.S Export from LLS. Pon of a"Iry.lexa'. <br /> Z Tra sporer signature dor experis only Data lea,mg U.S. <br /> W 17.Transprde 4cknoMedgmer t of Pool of Materials <br /> Transporter 1 Pnmedrryped Name Signature Month Day "ear <br /> O <br /> a <br /> N <br /> Transporter Pnnle6Typetl Name Signature Momh Day "ea' <br /> K <br /> r <br /> 1E.Discrepancy <br /> 1 Fa.Durepani Indication Space ❑ Qualms; ❑Type ue ❑Partial Relecbon ❑Full Repction <br /> Manifest Reference Number: <br /> 'Eb.Alternate Facility for Gene'iri US EPA ID Ncmber <br /> J <br /> U <br /> LL Facility's Phone. <br /> w 'Fit Sign aide c'Alternate FacirM for Generator) Month Day Vear <br /> ti <br /> Z <br /> te.Han,dol V/aide Repo[Vanagement Method Codes li e. codes for hazal Waste treatmentdisposal.and recycling systems <br /> ot 2 3 Notice: State of California requires <br /> 1 T gerneratorto photocopy and mail to <br /> 2C.Desgnatee Facirrq Owner fir Operator Certification of receipt of hazardous materials covered be the manifest except as noted In Item 18. DTSC With 30 days: <br /> nmMTped Name Sig reduce P,O Box 400 <br /> Sarralnantn.[a QSR17- <br /> EPA Form 8700-22 iRe. 3-051 Previous editions are obsolete. <br /> GENERATOR'S INITIAi.C'Opv <br />