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DlascE! nrint nr tvnA Wnrni dAginnpd fnr use nn al!tA (12-nitnhl typawriter.1 <br />Form Approved. OMB No. 2050-0039 <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS V <br />1. Generator ID Number <br />2.Page lot <br />3. Emergency Response Phone -7 <br />Manifest Tracking Number <br />01 45319 JJK <br />WASTE <br />5. Generator s Name and Mailing Address Generator's Site Add7sl (if different than mating address) <br />WOCV TOM, C.A W., 14 <br />Generator's PhonkTi' 17f1 -'—G'7 <br />6. Transporter t Company Name U.S, EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address,,U.S. EPA ID Number <br />W. <br />125 MENISIL—P-i �TPt Er <br />Fich-401 10, CA '3401 <br />Facility's Phone: <br />90-. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Conte <br />it. Total <br />12. Unit <br />q West. Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />QLrentlty <br />VW01. <br />V77S-Ir. M7MVVJWt0i,-LLi r--.!PrW-'U4 <br />mui <br />Elf - <br />'W . <br />11611 <br />XW <br />0 <br />Ul <br />'Ai SofltaENTi <br />3. <br />I4. Soodal Handling Instructions and Addltlonal Information <br />15. GENERATORISIOFFEROR'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 labele&placarded, and are In all respects in proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Primaq. <br />&porter, 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(x) (If I am a large quantity gereralor) or (b) (Ifl am a small quantity generator) Is true.. <br />GoneraWeVOfferors PdnWffyped Name Signatunk., - ktoo 132v <br />01-N4 <br />j <br />-4 <br />11LIntemational Shipments <br />0 import to U.S. El Export Ilrom U.S. Pba of erliryfeXlt <br />Transporter signature (for exports only): Pate leaving U,S.: <br />W <br />17. Transporter Ac:knowledgment of Receipt of Materials <br />I PrintedlTyped Signature Day r <br />Tsnsporier �Iann Ll <br />R <br />—c <br />Transporter 2 Printed/Typed Name Si nature z.,Moft. Day. Year., <br />16. Discrepancy <br />18a. Discrepancy indication Space El C)L,.* OTYP. ❑ Residue L1 Partial Rejection El Fu'fillejecdo.rl <br />Manifest Reference Number'. <br />18b. Aftemate Facility (or Generator) U.S. EPA ID Number <br />L) <br />rat <br />Facliftys Phone: <br />W <br />18c. Signature of Xtemaba Facility (or Generates) PR9.77 <br />Day -7year <br />13..Hazardou3 Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item laa <br />Name Signature Month Day Year <br />J <br />A Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />