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A -1 <br /> • - - �YJ \' ^- ' I <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t.Generator ID Number 2.Page t of 3.Emergency Response Phone- 4.Manifest Tracking Number . <br /> WASTE HANIR O �: �! .) :t .'y �r ri 3 3 5 Cil .. 0 0 0 2 5 0 4 7 9 JJ K�k <br /> 5.Generator's Name and Mailing Address Generators Site Address('d different than mailing address) <br /> Affi.leaf("Agowrmtaj. 6200 arms Street 'I99Q piccrA fid. <br /> t�a7rT> Tr?r N3 0A )40 <br /> Generators Phone: , �'r' j <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> Haz MatTrans. Inc t d A, T 0 8 0 0.1 8 0 (a <br /> 7.Transporter 2 Company Name U.S.EPA iD Number <br /> 8.Designated Facility Name and Sita Address U.S.EPA ID Number. I <br /> Siennei 1£VVetef <br /> 5375 Scout Boyle Ave. . <br /> I <br /> Allmon CA 9WW G 7 #01 53 i (4 9 <br /> Fadl' s Phone: p. <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tota! 12.Unit 13.Waste Codes <br /> HM and Packing Group(i!any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> >Fcan-R RA H azert Mste 3041 <br /> I p { <br /> P <br /> Z 12, I <br /> 3 <br /> i <br /> 1 <br /> 4. . <br /> 14.Special Handling Instructions and Additional Information i <br /> i. .'i) s3.i t .. i+ a a_ i ,#f)' 1; <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 /> I 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,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 quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatorsf0ffeforsPrintedrrypedName t Signature ;d`.;' r Month Day Year <br /> �I f.}i 1:�'_rY:FJ'y '� �. t;- '�,•3f.r, y,' 'l.k,r' - - f�:�r ..,1--�1G",� <br /> ..JI 16.International Shipments _ ' <br /> El import to U.S. ❑Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: t <br /> IT Transporter Acknowledgment of Receipt of MaterialsLLI <br /> r <br /> Transporter 1 Print rTyped Name Signature Month Day . Year f <br /> CL ..ry..°'�+f„. i��/N��, � E✓:J"f•� 7`d •.�--: �.�,.'' f,:"•',d:�'.'':iI`'•` _._. - <br /> Transporter 2 Pdntedlryped Name.. , Signature Month Day Year <br /> rr <br /> t8.Discrepancy <br /> 18a.Discrepancy Indication Space , ❑ Quantity ❑Type ClResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number.' <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number . <br /> rai Facility's Phone: ' <br /> _ Month, Da <br /> Year <br /> D Y <br /> � 180 Signature of Facility(or Generator) <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. 2.. 3. 4 <br /> ca <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Beni 18a <br /> Pdntedfryped Narse Signature - Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />