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Please print or type,(Form desi Wert for use an elite 12- itch ewriter. <br /> 9 ( P ) P ) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A 1, ,9 8 2 5 0 P; 2 3 t x(68f)- � 000252726 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> AM",Pal&#10M 'kV. 5 1J llwaita!rr -eot 19140 FAk!,coti Rd <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Haz :Mat Trans, Inc �. A i 0 8 tri 0 1 2 aS 0 0 <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 /> 5376 SotM Soyil-Ave. <br /> Vem n CA 90068 <br /> Faciil s Phone: JIM _ r CW A 0 ,'' i 3 +1 +6 <br /> 9 3- <br /> 9a. 9b.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(d any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> 0 t'�#t711�f�F.�'r�A, �•i�z2:�f�#cnas b'i�s:ste Mitt - - 'S.� <br /> Z 2. <br /> W <br /> (D <br /> 3. <br /> -19.Special Handling Instructions and Additional Information <br /> ,i.E.:'°JJL.r:'t.✓?.)"r i—)rr3ETt' 1.'T.-0'f.'X., .• I6ff-3(?s'ifrf"Sye�.7.:r• <br /> 15. GENERATOR'$IOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 EPA Acknowledgment 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 /> GeneratorslOfferors Prints <br /> _ - fp 4 '# Month Day Year <br /> } l 7'J <br /> .r 16.International Shipments <br /> a <br /> F- ❑Import to U.S, - ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> i <br /> w 17.TrensporterAcknowledgment of Receipt of Materials <br /> Transporter 1 PdntedfTyped Name Signature ft Month Day Year <br /> IL <br /> xx <br /> Z. <br /> Transporter 2;Pdntedi Typed Name. "Signature•' r '' onth Day 1F <br /> 18.Disaepanry l <br /> 18a.Discrepancy Indication Space ,❑'Quantity ❑Type '- ' ❑Residue ❑Partial Rejection v' ❑Full RejedYon <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> +a+ Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year } <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) i <br /> C 1. 2. <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 Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />