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Please print or tvpe. (Form desioned for use on elite (1 2-oitchl tvDawriter.) <br />Pn" Annrnvad r)KAR Kin )nrm-nnici <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />_1. Generator ID Number, <br />2. Page 1 of. <br />Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />JJK- <br />5. Generator's Name,.and Mailing Address Generator's Site Address (if different than mailing address) <br />A. 41 i'703 N Nfii. ; <br />+,E+ .I <br />"ANTECA <br />"A W.W <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S. EPA IDNumber <br />REC E IV Fn <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Desi j S, <br />�5w-lcllov WAWA %",FWGLkxm��; cop.p <br />U.S. EPA ID Number <br />6375 WIJTH BOYLE AVENJE <br />C A 1) 0 9 7 Q <br />3 0 9 9 <br />1.08 ANGELES CA 90JU3 ENVIRONMENTAL HEALTH <br />t 2 16W PERMIT/SERVICES <br />Facility's Phone: <br />9a. <br />9b. 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 Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1. <br />y 5e <br />0 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Info <br />ENEM*3410Y CONTAC I gOWNEC i -ftl-424-93M NAERI-DW ?)el 171 PR( <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 classified, packaged, <br />marked and labelediplacarded, 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 EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatoes/Offero(s Printed/Typed Name Signature <br />Month Day Year <br />16. International Shipments <br />E Import to U.S, ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LQ: <br />L1 <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter I PrintedfTyped Name Signature i <br />Month Day Year <br />0J <br />,jt r <br />Z <br />Transporter 2 Printed/Typed Name Signature <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity El Type Residue <br />El Partial Rejection <br />Full Rejection <br />Manifest Reference Number: <br />18b, Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />Facility's Phone: <br />LLj <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />!a <br />Z <br />0 <br />A <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />1 <br />7ad Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />