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' I <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.} Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manlie{s�t Trnacking Number <br /> 252916�` <br /> WASTE MANIFEST C A D `� 8 2 5 C :� �r 1 ! C [1£3`w (.; Q V V ul L.p JJ <br /> Generatofs Site Address(it different than mailing address) <br /> 5.Generator's Name and Malting Addrets i <br /> urdletj vVes*1,11 C'�fit3r f � tj.►t+a <br /> Afln fat GAk"i W V 57 "03!:t"% Jv�1 19W ptrCr:tmg Rill. ! <br /> 2 tr}Ckt t ('dA �r`15 <br /> W1 <br /> ,rbrtitTlett r"A 40 <br /> Generators Phone: ? u "' <br /> 6.Transporter 1 Company ame Y U.S.EPA iD Number !!! <br /> T.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> l <br /> B.Desgnated Facility Name and Site Address U.S.EPA ID Number <br /> k.rosby&(-)V tC.f1 I <br /> 1F.:30 W 17117 Street <br /> Long BOUCh CA 908513 <br /> Facility's Phone: r <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1Q.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wt.Nol. � <br /> cc 1. UN19,%,WASTE Aerosols. FI.At4 MA:6L <br /> cc <br /> Z 2 <br /> 0 � <br /> 3. <br /> 1 <br /> i� <br /> 4. <br /> 1 <br /> 14.Special Handling Instructions and Additional Information <br /> 15, GENERATOR'S/OFFERORIS 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 tabeledlplacardad,and are in all respects in proper condition for transport according to appiicable intemational 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. I <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quarRy generator)or(b)(ifI am a small quantity generator)is true. <br /> Generator's/Offerors PrintedfTyped Name S'agnature Mordtt Day Year <br /> j <br /> 16.Intematibnal Shipments <br /> D 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 Printed/Typed Name Signature Month Day Year <br /> O <br /> U) Month Day Year <br /> Q Transporter 2 Pdntecb7yped Name S�gnaturta. <br /> 16.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑F,1 Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> Facility's Phone: { <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year S <br /> Z <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU� 1 2 <br /> 3. 4. <br /> I <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name Sigrature Month Oay Year 11 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />