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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1.A09873P5G441, 1 ("01 A=4- 700 012422$17 JJK <br /> 5. me(a��o_r�rya�pg,a���t��inygd s <br /> �.\tfl'!4t'4q({t pfpR{j�_y Generators Site Address(ifdiRarent than mailing address) <br /> I <br /> 499 T)t 2373 <br /> !"'p P £MAF',PO.�pc1 14)A0 <br /> n+ Tt <br /> Geriaofs phone: 91113 41111 S7C7f:KTUf3 +A SEQ06 <br /> 5.Tia' )t� T I MFN rAl. <br /> SERVICES D.6.�' I' a s �7 0 a <br /> 7.Tmisponer 2 Company Name <br /> -- _. _-d-�y �tyNap�e ar�d$dggdya�sIIC FPA IOhklm68t__ <br /> 8.Dtial 1vr4nWgiC1{ iLE AVE,II.OQ JUL 1 '1 206 U.S.EPA ID Number <br /> 531:s HiWMli BC9YLE.AVENUE J V L <br /> LOVS CA 90obs <br /> r32:TS277.1°k00 CAi309703099 <br /> Facifiry's phone: TH <br /> ga. 911).U.S.DOT Description(including Proper Shipping Name,Filmed Class,ID Number, iners 11,70101 12.Unit <br /> HM and Packing Group(Rany)) DEPA.. 17a Type Quantity WRJvol. 13,Waste Codes <br /> 0 1?40"xh,:R1,HAZARDI YdASTE.Set-10(op y cl, JtDa) <br /> f f 6"00 <br /> 00 P <br /> z z. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions,and Additional Information <br /> EM[WIENCY CONTACT i C14CMITREC 1800-424-9300 NMRG#9iti:171 PI O MI,,k,It Wi-API Lit OK.Y <br /> SO4.M,AER°ed7REr(iNT,SWEET'w POJ#A1101794434 a APPROPRIATE PF.R^s41NA5 PROTFc7jYF FOMPMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Iherebydeclare that the contents of this consignment are fully and awurately described above by the proper shlppirg name,and are classified,packaged, <br /> marked and IabekNplacarded,and are in all respects in proper condition for transport according to applicable inkmational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I candy that the contents of this consignment oonfomr to the terms of the atl ad EPA Acknowledgment of Consent. <br /> I cergfy that the waste minimizabon statement identified In 40 CFR 262.27(a)(R I am a large quantity generator)or(b)(If I am a small quantity generator)is We. <br /> enem rslORerors PnntedfTyped Name ` Sighatum Month Day Year, <br /> ...r i6.Intemafional Shrpmenba <br /> i ❑Import to U.S. -- 11 Export hcon U.e Part ofenwext: <br /> Transporter signature(for exports only): - _ -- Date leaving U.S.: <br /> w 17.TranspoderAcknoWedgm m of Receipt of Materials . <br /> o TranrtarT PrintedlFyped Name ,. Sgnature - Month Day Year <br /> f�KJ x.~"._--..� � aa,, ''IG-^'7'x.'1" n1F �✓ <br /> G T1an11er2 Pnnted?yped Name Wre Month Day Year <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Que^ay ❑Type El Radom ❑Partial Rejection El Full Rejecon <br /> Mantles(Reference Number: <br /> 18b.Aitemate Fadlity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signatureainomate Facillty(orue mbr) Month Day Year <br /> Q <br /> 2 <br /> h19.Hammous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. 2. 3. 4. <br /> 1 20.Designated Facility Owner or Operator:Gertifiwtion of receipt of halerdoue materials covered by the manifest except as noted in Rem 18a <br /> Printed/Typed Name SignaNre Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />