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4 <br />OILY V)� <br />., m....., e..d., not in. um nn alae f1 1 Wrowdlar 1 <br />Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS 1. no t r ID Number d�..r L <br />coo J <br />2,Page 1 of <br />l <br />3.En1@fgepc4ge;poys 0PhOone <br />7 CUU 24 `J <br />4. Mani(eOst Tracking Number <br />J J K <br />WASTE MANIFEST / <br />Generator's Site Address if different than mailing address) <br />5. Generators Name and Maili�ng//Address; O.S <br />embSf Phone: <br />6.TrenspaeV6P Environmental Services DUFW413262 <br />7. Transporter 2 Company Name - U.S. EPA ID Number <br />8. Designated Faulty Name and Site Add r 1 n C. U.S. EPA ID Number <br />6880 Smith Ave. <br />Newark, CA 94560 CAD980887418 <br />510-795-4400 <br />Facility'sPhone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />1o. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (gany)) <br />Quantity <br />WLNol. <br />1 /t,/— <br />Q <br />Z <br />W <br />2. <br />f'! <br />3. <br />4. <br />14. SpeclI Handl!Instructions and Additional Information -171 <br />15. GENERATOR'SIOFFERORB CERTIFICATION: I hereby declare that the contents of this consignment are fully and amnately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, 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 Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I ceNfy that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity generator) or (b) (if I aa small quantity generator) is true. <br />GenemtorsfOBero's Printed7fyped Name �(/ Signature Month Day Year <br />41 kt Vgr26*5 i( / () 22- /d <br />—+ <br />F <br />16. International Shipments <br />❑ Import to U.S. El Export from U.S. Port of eMrylexit: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 Printeciffyfilid Name Signs Month Day Year <br />a <br />QTransporter <br />FitntedfTyped Name Signature Month Day Year <br />C <br />t- <br />Discrepancy <br />j18. <br />18a. Dlscrepancy Indication Space ❑ Quantity ❑ Type ElResidue El Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Ahemate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />LL <br />Maj <br />FacilitVs Phone: <br />life. Signature of Alternate Facility (a Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <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 hem 18a <br />Printedrfyped Name Signawre Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />