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ptAnrra print or tvne. (Form desioned for use on elite (12 -Ditch) tvoewriteel <br />Form Approved, OMB No. 2050-0039 <br />A Form 8700.22 (Rev. M5) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />11. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Man Nest Tracking Number <br />017145319 J J K <br />WASTE MANIFEST <br />+ �"-`�a - - - - - <br />t <br />I6 --V 1674"' <br />5. Generator's Name and Mailing Address Generator's Site 9ddres (if different than mailing address) <br />� <br />�1:.tF',Iv'lEk:ii : ... . ..... . ..��`ar:r� - "., -`fir, ,a: i �•Z � <• . <br />;T0C i 01 CA 14' <br />Generators Phorukr 4370-x1 W7 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />RraP,10EP►eig;i)PIfWXTAI. ':;eP:10ES IPTG CAM44 t,3- , <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site AddressU.S. EPA ID Number <br />tJA E x TEMC -R'C AJI. 1!Ve tTb3t4�i; .t1 t °1a71 J07 <br />t 125 MEN gl STPIE T <br />Flt:a>?46ND, CA 9401 <br />SnU-2434.3 <br />Faclllty's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No, <br />Type <br />HM <br />and Patting Group Cd any)) <br />CK?ndty <br />WtNol. <br />o <br />SOLID, P JS, 9. PM jC1�1 MIJI.ItA. LE-AC31 <br />� �t <br />Z2. <br />_ � - w _ t <br />Y <br />936 <br />a 3t7PEAIf1'► <br />' ;�. i'� <br />l� <br />4. <br />.. <br />.. <br />a. -i <br />14.e1 Handling Instructions and Additional Information <br />�' <br />3r1�t3ft�i171 9� 311^f€�tl EFCtA17i <br />�1?. L�#T��c:ii7i�: R,iDd€�s �CAYrif�Gtfi�tT.tC _ . <br />-^ <br />tP.h1CkE!'t3 stio" ee TR Ao-vo AND ILKE APS, u13 PPE JJ <br />15. GENERATOR'SIOFFEROR'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 International and national governmental regulations. if export shipmentand I am the Primary <br />Exporter, t 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) (f I am a large quantity generator) or (b) (III am a small quantity generator)r Is true. . <br />GenerateVOfferoes Pdnted/Typed Name Signaturq J r Yeas <br />! <br />-1 <br />international Shipments <br />❑ Import to U.S. ❑ ExpodhanU.5. Pbrtd'en1'yisodf~ ' <br />116. <br />_ <br />Transporter signature (for exports only): Perla t0 US-: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter) Pg'nted/TyppdNamMonth Dgy r <br />on <br />Warne } re i _ }` � <br />Transporter 2 Printed/Typed Name Stnature _ DAY Year'- <br />18, Discrepancy <br />18a. Discrepancyr-� t! <br />Indication Space p El Quantity L1 Type ❑Residue EI ❑FuM.R*cAon.. .� <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />ua.. <br />Facility's Phone: <br />W <br />18c. Signature of Ntemate Facility (or Generator) <br />Month D <br />Z <br />- <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. <br />3. <br />4 <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Be <br />PdntednWed Name Signature Year <br />A Form 8700.22 (Rev. M5) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />