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: <br /> Please print or type.(Form designed for use on elite(12-p • <br /> �pewriter.) <br /> UNIFORM HAZARDOUS 1.-1-ator ID Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track......... <br /> 5,Generators Name and Mailing Atltlress -w . !G D C <br /> Generators de Atldress(if different Chari mailing addr ss) ' la D r <br /> 140 LAI HjP )Pf io <br /> Generators Phone: LAIb}tJsiFR, ±'A W? :Vt0 <br /> 6.Transporter 1 Company Name <br /> `At('0'llkj A{'1♦) ' 7ijt;t{(f„MCS,iW: US.EPA IDNumber <br /> 7.Transporter 2 Company Name <br /> r-.Annnt)tt f1d.. <br /> U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Atltlress <br /> )(�fJ!)'Ip.I,I..0 U.S.EPA ID Number <br /> t 1OB* vie.!TE'Ntit:}<,fm <br /> tf.�Rt�N. ilr +,.(afJ1.7C»IA, U57d'+ i:A[tiNBa.Rdy:(1f{f <br /> Facilitys Phone: `)Il> T"}{);M71) C.4 -- <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Pecking Group(if any)) 10.Containers <br /> 11.Total 12.Unit <br /> 1 I IA/ARD jUS VdA f l rl)1.}I,}, t4 No. Type Quantity Wt./Vol. 13.Waste Codes <br /> 1'::'A��tklNf:': .l`9t31'fhit}fC?1i1H) Pi.V3LPa!'.R. ) t.1f. <br /> Owe 4t.; <br /> Z 2 _. <br /> (Y I <br /> 3. <br /> I� <br /> 14.Special Handling Instructions andAdditional Information <br /> iH, . iL.E# EtulaC7LNd}Ht RyF'Ftl.i€1daF,Htj{ g t aj1 a;jfsfif.NT <br /> N Fr�x4 PgTE fy r71 �i TINE'C'i.k,iTFlfdt,i <br /> E.kE k f7tii dP1 7 t <br /> 15. GENERand labelATOR'S}OFFEROR'S CERTIFICATION: I hereby declare Nat the contents of this consignment are fully and a=ralely described above b he ro er shi in name,and are classiaed,packaged, <br /> Exporrtter,I certify II <br /> Placarded, <br /> he contents of this coins gnmenl conform to hl respects in proper e tenstion transpord arid <br /> the achetl EPAAcknovAedgment of Consent. y p p pp 9 <br /> n9 applicable intema6onal and national governmental regulations.If export shipment and I am the Primary <br /> I cartiy that the waste minimization slatertrent identified in 40 CFR 262.27(a)(if 1 e a a large quantity generator orb dl am t.small quantity Generalors/ORemrs Prmt,&Typed Name ) O( q ty generator)is true. <br /> Signature <br /> --t 76.International Shipments Month Day Year <br /> z LJ Import to LLS. <br /> Transporter signature(for exports only): F-1 Export from U.S. Pon df entry/exit: ' r <br /> w 17.TransporterAcknaMedgment of Receipt of Materials Date leaving U.S.: <br /> 0 Transporter i,P'ed(ryped Name <br /> .` 1 Signature <br /> r. v ..� a Month Day Year <br /> QTrensponer 2 Pdn ypad' me. y r J <br /> Signa w re _,. < L� <br /> Mont ay Year r <br /> 18.Discrepancy <br /> ibe.Discrepancy Indication Space <br /> ❑ Quantity ❑Type <br /> El Residue ❑Partial Rejection <br /> El Full Rejection <br /> IZ 18b.Alternate Facility(or General or) Manifest Reference Number: <br /> J <br /> U U.S.EPA ID Number <br /> LL Facility's Phone: <br /> w 16c.Signature of Alternate Facility(ar Generator) <br /> Month Day Year <br /> w 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. <br /> 2. 3. Notice: New federal form. State of <br /> 20.Designated Facilily0wnerorOperalocCerlificationofreceiplofhazardous malerialscoveretlh me California requires generator to photocopy <br /> I <br /> Printed/TypedName Y p and mail to DTSC within 30 days: <br /> signature P,O. Box 400, Sacramento, CA 95812-0400 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />