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faIeaise print or type. IF orrn desiqned for use on elite (12 -pitch) tvoewnter.) <br />Form AL)nrnvpfj OMR Na 20.90-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM NAZAROOUS <br />1 Ge ncratur ID Number77 <br />Emergency Response, Phone <br />14'Manifest Tracking Number <br />WASTE MAN <br />•FLE <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than trading address) <br />ltq- WA zipwktan k <br />i, a, 16an <br />Si rc kim, CA 962M <br />Generator's Phone:2(141 2154 14f�ki <br />6 Transporter I Company Name US EPA ID Number <br />MvWK;fta 71� <br />1 <br />7 Transporter Name U.S, EpA ID Number <br />,2,�pmpany <br />8 Designated Faciity Name and Site Address US EPA ID Number <br />Facility's Phone: <br />9a. <br />9b, U.S, DOT Description (including Proper Shipping Name. Hazard Class, ID Number, <br />10 Containers <br />11 Total <br />12. Unit <br />11 Waste Codes <br />No, <br />Type <br />HM <br />Tend Packing Group (it any)) <br />Quantity <br />Wt Ivol <br />q <br />0 <br />ef I, <br />Z <br />2 <br />LLJ <br />r <br />OCT <br />I 162015 <br />2015 <br />4 <br />E IR <br />NMENTAL <br />14 01-L4 <br />C77)�PT%ACNIT <br />14. Special Handling Instructions and Additional lirformation <br />C LV*363 <br />xMill ACT4,Zft -RA, <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydescnbed above by the proper shipping name, and are classified, packaged, <br />marked and labelediplacarded. and are in all respects in proper condition for transport according to applicable international and national governmental reguistrons. 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) lif I air a large quantity generator) or (b) If I am a small quantity generator) is true. <br />�enoratoot!Offeribr`s Printed/Typed Name Signature yY <br />'4 <br />=j <br />1.— <br />16. International Shipments <br />0 Import to U.S. ❑ Export from U.S Port of entryl x1t: <br />K <br />I Transporter signature (for exports only). Date leaving U.S. <br />.SIX <br />IX <br />1Aj <br />17 Transporter Acknowledgment of Receipt of Materials <br />"Apojfr 1,Rrin 15�1 1) a, Y0, <br />Trp ed Name btu M0 y <br />pp <br />0 <br />p <br />Z <br />Transporter 2 PrintedlTyped Name olgriaTure" Month Day Year <br />18. Discrepancy <br />18d. Discrepancy Indication SpaceF <br />D Quantity L1 Type EJ Residues Partial Rejection Fill! Rejection <br />Manifest Reference Number: <br />>- <br />18b. Alternate Facility (or Generator) U.S EPA ID Number <br />:3 <br />Facility's Phone: <br />UJI <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />rn <br />119. Hazardous Waste Report Management Method Codes (.e codes for hazardous waste treatment, disposal, and recycling systems) <br />-T <br />20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br />Prtnled,Jyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />