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r <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Fortin Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTracktng Number <br /> WASTE MANIFEST U A 3 9 8 2 5 f� 8 � 1 rt 9 7 0002 5009 i JJ F` ' <br /> 5.Generators Name and Mailing Address Generator's Site Address(Kdifferent than mailing address) 1 <br /> E It% 1 �!5[£ ttsfC.EaC'rra U' .Cs, <br /> tign'Pat�.�L,fi�-nMtV.5200•dim St c-*l its�'Icr(A Rd. <br /> t,rl.At[Tl�t'r a t:/'i '��i 40 SIOC'KtO+ CA `3621;? I <br /> Generator's Phone: r, r <br /> S.Transporter 1 Company Name U.S.EPA ID Number <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 /> t,::tcr>iatrlt�C�+i�rtt�tt j <br /> 1&V VV- 17ttr 1,3Ireet <br /> Fadfitys one: 'CC € <br /> 9a. 9b.ELS-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Con(ainers 11.Total 12.Unit 13.Waste Codes l <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Nol. j <br /> 0. t WASITE Aefosds if <br /> Z2 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information r <br /> `; -- <br /> f- - .- �: '„� - .�y' • �r� �t�F. .�:•. .• - -SJ-{, RFs E? 4 �F �?�'C7Cf«E.�?.s. •. - -I <br /> 66f-0o;o <br /> 15, GENERATOWS10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershippingname,and are clas0ed, d '. <br /> marked and labeledfp€acarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and!.am the!04(Ery' <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknoWedgmeni of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Month Day, <br /> GeneratorslOfierors Prirtedi Typed Name Signature - Year <br /> r <br /> .: 16.International Shipments - <br /> ❑Import to U.S. -❑Export from U.S. Port of"try/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 0' 1 T.TransporterAdmowledgment of Receipt of Materials ' <br /> W Month Day _. Year <br /> Tran rter 1 Pn`rpedlTyped Name <br /> Signature y j / f <br /> Z Transporter 2 Pdntedi'Typed Name Signatuie - . Month Day Year <br /> a `F <br /> r— - <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Reject on Full Rejection'` <br /> Manifest Reference Number. <br /> 18b,Alternate Facility for Generator) U.S.EPA ID Number <br /> u FwAity's Phone: <br /> W 1 Bc.Signature ofAltemate Facility(or Generator) Month Day Year <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3, 4. <br /> LU 1. 2• - <br /> 20.Designated Facility Owner or Operator.Certifiication of receipt of.hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> PriniedfTyped Name Signature - Month Day' Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />