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Please nnt.or type.(Form designed for use on elite(12-pitch)typewriter.) form_4proved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A D 9 8 21 :5 0 8 :2 ,'3 T 1 � -��-��r 0 0 0 2 5 0 0 9 " jJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if diffe€ent than mailing address)- <br /> Ur dfiCxl VVestern C4o_,en, <br /> AW-Pat Afiertnet'w,52 41a SVcwt . , 19W Ry.cou Rd <br /> GcftnnWCe CA 9E7040 " .4Pck on („',A 95 24”) <br /> Gsnerators Phone: <br /> 6.Transporter 1 Company Name a U.&EPA ID Number <br /> of At1r�I"I Ca4f1S; T4+" .,C- A "_V 0 ` 4.`,0 <br /> 7,Transporter 2 Company Name U.S.EPA?D Number. <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number' <br /> �st�'CiC1 is vvmet'.Tec`r OOPAR <br /> -;Offr y <br /> 5376'YVe"XM CA 900,58 <br /> f <br /> Facility's Phone: QQQ .7 <br /> ga 9b.U.S.DOT Description(rx;luding 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 WL/Vol. <br /> C 1 N rt-RC..!RA.tHazal'LiCJLIs taVEt t# <br /> Uj <br /> tzui„ :C q!Xi `rix ria:Gr . Ln1.x3r '.c a <br /> ' <br /> 3. <br /> 4;, . <br /> 14'Special Ha`ndlmg9nstruchohs'and Additional Information <br /> 3}i.r{7, �rY +?�`t.�+T� U _I t$,2'`?a}.).:F+TIt � 1.`xiF? > I3T ri l f✓._ :r�� iS Yi�n�r rk'�'tjr ree s y, <br /> 15. GENERATOR'SfOFFHROWS CERTIFICATION: I hereby declare that the contents of this°consignment are fully and accurately described above by the proper shipping name,and are classfied,packaged, .+'. <br /> marked and labeled/placarded,and are in all respects in proper condidon,for transport according to applicable tntemational and national govemmeintaI 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,attach6d EPAAcknowledgmeni of Consent.- <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)_(9 l am a largs•quantity generator)or(b)(if I am a small}uantity generator)is true <br /> Generator'sl0fferors NntedfTyped Name - ': Signature _ Month Day Year <br /> _j 16 International Shipments' Port ofen <br /> !exit <br /> U.S. <br /> F- ❑import to U.S. ❑Export ff�+m S tiY :- <br /> a Transporter signature(for exporis only): Date leaving U.S.: <br /> W 17.TranspotterAdmowledgment of Receipt of Materials " <br /> t i Month' Day Year <br /> � <br /> Transporter 1 Printedffyped Name SignatureIL <br /> - ,•s � i� - <br /> HreS' nature°' t Month Day Year <br /> a nsporter 2 PrintedlTyped Name . . ' <br /> 18.Discrepancy <br /> 18ar Discrepancy Indication Space ❑ quantity ❑Type' ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> r. <br /> LL Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> z <br /> V19-Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems). <br /> G 1. 2• 3. 4• <br /> 20.Designated Facility Owner or Operator:Cer0cation of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />