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.WC- <br /> _1 <br /> .. <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAROOUS =LO <br /> er 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 11103 2 '1 1 011351:673' JJK_ <br /> 5.Generators Name and Mailing Address -. Generator's Site Address(if different than mailing address) <br /> IR30 0 M90 ST <br /> C C�V�C�1 CA 95338 MIMYECA Cly 83335 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> R7UtfG=[CUMYALSERUXE.S ICAD02027703G <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 20000 AU,\NM0A SMET <br /> Mau, r= CA ��aa CST®>�®®a3��a <br /> Fadlitys Phone: (32.011337-700 <br /> 9a. 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> _ No. Type Quantity WLNoI. <br /> 'C" G� D0 <br /> fr o, UN ►5, a� t.�cb�I fel ®®g Y t� � ` <br /> UJI <br /> 2. <br /> UJI <br /> f. <br /> s� :•.. 4'• .1r� <br /> A 1. .M :i-'r •e. .� <br /> 14.Special Handling Instructionsland Additional Information ' <br /> C9Ga 1313 <br /> 931:171 11 PMRLE 0 MI:MUMBE*EB11M(ENCV COMM--CHEC`1 C SLZNL424.8 4 s <br /> IQ �GJ" IFS;9011:.M.M.-AFMCI '�LUE FERMML FROT�CM (EQD�C'?TEO$ <br /> C IL id b D\4 d 9 D W A I/o/42 k9a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the�coMents of this consignment are fully and acci 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 internal onal 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 EPAAcknowledgment of Consent. <br /> I.certify that the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(idl am a small quantity,generator)is true. <br /> toes/Offerors yped Nam Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter.signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnntedffyped N Signatu Month Day Ye <br /> ZTransporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceLJ (�.� <br /> Quantity S ❑Type 1:1 Residue ❑Partial Rejection Y�uO Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facft for Generator) �lAt� �` U.S.EPA ID Number <br /> t to 00 N o <br /> at FaaTitys Phone:C f]O I� 3��- v'C <br /> W18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LAJ 1. 2. 3. 4. <br /> 20.Designated FarxTriy Owner or rator.Certification ai receipt of hazardous materiats covered by the manifest except as noted in Item 18a <f <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.305) Previous editions are obsolet . DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED)- <br /> 11623.0835 <br />