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Form Approved.OMS No.2050-0039 <br /> Please print or type.(Form designed for use on e'Ie(12-pitch)typewrter. p page t of 3.Emeryency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.Generator ID Number J J K <br /> WASTE MANIFEST C A Ll 9 H 2 5 iJ P :� (i 1 <br /> 4(Ya-fU3�f-KziO7 i <br /> S.Generator's Name and Mailing Address Generatofs Site Address(il d'AMrent than mailing address) <br /> l nified western Gnicer9 Lt wY f3 <br /> Atari Pin GUIllefTwatr-52(.)O: t,ai4,&1rr ! 1q?T0PtrrrA P S <br /> rmnerca (.A. y(ii14t) o!Ocklat UA 4;i T <br /> Generatofs Phone: , <br /> U.S.EPA ID Number <br /> 6.TrenspoMr 1 Company arae <br /> Hoz Mat Tt2ins, Inc i. A er S 0 U 1 v it <br /> U.S.EPA ID Nuu mber <br /> 7.Transporter 2 Company Name <br /> a.Designated Facility Name and Site Address U.S.EPA ID Number <br /> LWAlennOMIRRIoon <br /> 2000 N.AMUMM jgreel <br /> Crxygytun CA 9071 <br /> Facility's Phone:DOT De. -- <br /> S. secration(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Ung <br /> 9a 9b.U. 13.Waste Codes <br /> HM and Packing Group(a any)) No. Type Quantity W[Nol. <br /> C 1. N7+rrR(:RA.,HaztlttkA"ti'v lvs P i.lT�gr7 3d} <br /> 79 <br /> P+ <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> 14.Spatial Handling Instructions and Additional Information <br /> .seliwskt;�eT zr:>m s,la�ar. uL, <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 new,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,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent - <br /> I certify that the waste minimization statement identified in 40 CFR 261(if I am a large quantity generator)or(b)IBI am a small quantity generator)is true. <br /> Generatofs/Offerers P!nted/Typed Name - Signature i Month Day Year <br /> -1 16.International Shipments Import U.S. ❑Export from U.S. Pod of entryleAt <br /> = Transporter signature(for exports onty): Date leaving U.S.: <br /> K 17.TransporterAcknawledgment of Reo*of Materials <br /> C Transporter 1 Pnnted/Typed Name Signature Month Day Year <br /> Tnsporter 2 Printedi Name Signature MohM Day Year <br /> ra <br /> C <br /> r <br /> ♦ 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> sae. Facility's Phone: <br /> W 18c.Signature of Altemate Fadlity(or Generator) Momh Day Year <br /> G <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazallous waste treatment,disposal,and recycling systems) <br /> C 1. t 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item tbe <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />