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f � ! <br /> Y <br /> Please print or type.(Form designed for use on elite(12-pitchYty`pewriter.) - Form Approved.OMB No.2050-0039 <br /> UNIFORM tiAZARD0u5 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A D 9 8 2 5 0 < r,` ;3 t ire}•t -` 000250268 JJ K <br /> 5.Generators Name and Mailing Address Generators SilaAddress(if d'riferent than.mailing address) <br /> f..)Nflef,)wC'r5Q>rt n Grucj 's UINIVl rj- <br /> Attn:tit!ok0e'rf*t, !MO ShOle-Styr-%A I M ftco i Rd. <br /> C;on t1 fu- CA 90040 CA :36)21: <br /> Generators Phone: � ' 3 <br /> 6-Transporter 1 Company Name U.S.EPA ID Number I <br /> t'Iaz A.rlat Trans, )fir G A 1 0 8 0 Us? 8 0 C 11 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and SneAddress U.S.EPA ID Number ;•� <br /> T1 <br /> +�r".�1f�y^jaYt�1• SBoyle <br /> ��ttyit.� it - ••?I <br /> 5 S5,04M <br /> 'J,WTM CA 900M <br /> Fadlity's Phone: A. <br /> ga I 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(if any)) No. Type Quantity Wtivol. <br /> 1. ' <br /> - <br /> W <br /> rUA 2. 1 <br /> 3. <br /> ) <br /> - E <br /> 4. 1 <br /> 14.Special Handling Instructions and Additional Information <br /> f: t..21; <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 /> marked and labeledlplacerded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.4f 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. <br /> I cefify that the waste minimization statement identified in 40 CFR 262.27(a)(ii 1 am a large quantity generator)or(b)(if lam a small quantity generator)is true. <br /> Generator'slOfferor's Prinfedlfyped Name Signature Month Day.- Year } <br /> t, - <br /> c <br /> -1 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> a Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials r <br /> rr, Month Da Year 1 <br /> tY Transporter 1 Printe�fTypad Narrre � Signature �; � , Y <br /> O e l r � <br /> � � ,�".�i '�f,• s _r:'�� �,a-,•"' . '�sr .' S <br /> Z <br /> nsporter2PrintedffypedName ,�: ignafu '.�" Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection i <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Faciiityrs Phone: <br /> LU 18t.Signature ofAltemate 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) <br /> Q 1• 2. 3: 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as.ncted in Item 1 Is <br /> Printedl3yped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />