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C ert=f or' WhIi a .oOY io 1'7'Q 0 [IQ)( 406 Saf:r,Tnlenla, Ca. 95812-0400 �1 ;r &wq" <br />Please Dnnt or Noe. (Form designed for use on elite (12-oitch writer.) Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />�L..00Z)2-S�i f �Z..-0�"S <br />2. Page 1 of <br />3.ERire <br />4. Manifest Tmcking Number <br />0 JJK <br />WASTE MANIFEST <br />S. Generatols Name and Mailing Adtlress'Y' /'n _ Generatg(�Sbe Address ddilferenttha a" address <br />v p f�+��- 4.-�°' (off <br />a � CAS � <br />O l� I11?--�- P <br />�O 3 <br />r�eiato7s Pfione: `•`•`� <br />6. Transporter 1 Company Name - U.S. EPA IO Number <br />f.:veyllreara Environmental Servic CAM2413M <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address E1ri' i'F2Ti !}ti, iTsu. U.S. EPA ID Number <br />510- 795 €M Siniff,Ave <br />WwarF., ca sA5tati CA09019?.t)7418 <br />Facility's Phone: <br />gra <br />91d. 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 Pecking Group (if any)) <br />Quantity <br />WlNol. <br />3 &W/'7 3��' <br />v <br />4 y.�rM� L A- . <br />z <br />loo <br />Z.Jq 0A (L, <br />7 uNl mss' <br />�. <br />I <br />- <br />Sff { <br />3. <br />4. <br />14.Special Handling sWctionsa99�AddNonallnformahm t . A PPROPIRM TE PPE <br />` <br />i ? '! -ERGO �tpj. I — 1 �g <br />ff1 <br />-i-9•z_ M7- !33 <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 dassified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. N export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the temxs of the attached EPAAckrwwledgment of Consent. <br />I certify that the waste minimizafion statement identified in 40 CFR 262.27(a) (t I em a large quantity generator) a (b) If I am a small quantity generator) is We. <br />Geng@tors/Oberoes Printedrr ped Name Signature Month Day Year <br />_ <br />!. � <br />F <br />16. International Shipments 1:1 Import to U.S. ❑Fxponfrom U.S,•_ Pon of entry/exb: <br />Tanspoder signature (for exports only): Date leaving. U.S.: <br />w <br />17. TansporterAcknowledg of Receipt of Materials <br />{/ <br />C <br />Transporter l Printed/TUM11I Signature /� Ml Day Year,,. <br />Transporter nntedrTypedName"nature Month Day Year <br />K <br />F <br />.N <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ 1 ❑ I <br />El Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Altemate Facility for Generator) U.S. EPA ID Number <br />J <br />U <br />LL <br />Faalitys Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in tem 18a <br />Printed/ryped Name Signature _ M1 y Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />