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f I <br />Please print or type. (Form deall nod for use an elite (12 -pitch) typewriter) <br />Form Approved. OMB No. 2050-0039 <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INMAL-1000Y <br />UNIFORM HAZARDOUS <br />1 1. Generator ID Number <br />C AIXW1W.1&5f J <br />: <br />2. Page I of <br />3. Emergency Response Phone <br />1; 371 V <br />4_ftffwt Trucking Number <br />017145319 JJK <br />WASTE MANIFEST <br />16- 47 <br />5. Genarab's Name and Mailing Address Site 6077 Of Offerent than mailing address) <br />I'm <br />9TOCP TOM, CA 16a 14 <br />Generatoes Phonkri 41TJ-5-V7 <br />6. Transporter t Company Name U.S. EPA ID Number <br />'AP!XES 64G, CIAD044=6% <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />8. Designated Facility Name and She Address, U.S. EPA ID Number <br />.e" PIS TECHNICAX, <br />f 125 HEN ti StnftT <br />Flt>fjOi 0, CA -3"-1 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Degalption (including Proper Shipping Nam, Hazard Class, 10 Number, <br />10. Containers <br />11.1W <br />f2. Unit <br />13. Waste Codes <br />No. <br />Type <br />HIM <br />and Pecking Group [if any)) <br />Quan* <br />WLA(d. <br />A <br />1.VVK-307. . W-MIt! V77173M.11."LL7 butlaVmlliue:s <br />UU11 <br />Eir <br />V <br />11M <br />XA)4 <br />SOW, �QS_ 9, PM iCHORWUW. L640) <br />Ll <br />Z <br />WI <br />LW <br />If] <br />VQ <br />4. <br />114. Special Handling Instructions and AWffonal InformationFSCrt <br />W 17141WI7 AND I–MEP PPI! <br />t5. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are llulty and accurately described above by the proper shipping name, and. are classified, packaged, <br />marked and labe"plecarded, and are in all respects In proper condition for transport according to applicable International and national governments[ regulations. N export shipmentand I am the PrimEq— <br />ExpDr* t cerilly, that the contents of this consignment oDnbm to the terms of the attached EPA Acknowledgment of Consent <br />I corffy that the wade minimization statement (denlilled In 40 CFR 262.27(a) (If I am a large quantity generator) or (b)jIf1 am a small quentity gameratory is true. . <br />Genera errilfaron'e PrkltedfTyped Name Signatum_.- WIPA1111- n- <br />-YAW I <br />-4p <br />f <br />18 Intorna" Shonents <br />El Impato U.S. ❑ Export from U.S. Port of eniry/W' <br />Transporter signature (for exports only): A �Pala leaving U.S.: <br />1.r <br />17. Transporter Acknowledgment of Receipt of Materials <br />reporter I Pqnted/Typpd -6 DW YAW <br />Transporter 2 PrInted[Typed Nam re Mar6f Doi <br />18, Discrepancy <br />18a. Discrepancy Indication Space ❑ Quan* ❑ Type ❑ Residue EI Partial Rejection <br />Manifest Reference Number. <br />18b.Afternala Facifilly (or Generator) U.S. EPA IQ Number <br />F.dlity', Phone: <br />LLI <br />18c. Signature of Alternate Facility (or Generator) <br />Do 7.Yaw <br />t <br />I <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. <br />2. <br />3. <br />20. Desiginsted Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item Ise ".4 <br />PrIntediTyped Name Signature N" Dent Year <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INMAL-1000Y <br />