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Form Approved.OMB No,2050 0039 i <br /> Please print or type,(Form designed for use on elite(12-pitch)typewriter.) .: 4.Manrfest Tracking Number f <br /> 1.Generator.lD Number 2.Page'1,of 3,Emergency Respon_se Phone <br /> UNIFORM HAZARDOUS 00025009.6 JJ K:::: I <br /> WASTE MANIFEST .. C g p 9 8 2 5 0 8 2 s 1 1 <br /> go"$&5�� <br /> 5.Generawrs Name and Mailing Address.. eGeneraWrs Site�ddress(if d'dterenI than mailing address) <br /> ut eri , u_v c " 4 <br /> AM:Pat G itf whew,52M 81*18 SbiMt. ., 1990 PIS Rd. <br /> fierce CA 90040 Stockbor► CA'9621 :i <br /> Generators Phone: U.S.EPA iD Number <br /> 6,Transporter 1 Company ams. :! <br /> Hoz Mat Tfant , Inc. C A Tu Q B .� 0 1 2 $ (? fl <br /> U.S.EPA iD.Number <br /> 7.Transporter 2 Company Name ' q <br /> U:S,EPA ID Number <br /> 8,Designated Facility Name and Site Address " - j <br /> I J <br /> Siemens Water Tie.Corp• j <br /> 5375 Sautli 8oyte Ave: = <br /> Vernon CA 90058. i <br /> Fact s'Ptrona, i <br /> 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. 9b.U,S.DOT Description(including Proper Shipping Name,Hazard Class, Number, ' Quantitty . WSJWoI. <br /> HM and Packing Group(ii any)) No. Type <br /> Hazardous Waste.Sofid <br /> �c Non-RCRA. <br /> H <br /> east <br /> °MLLI <br /> LU JAIA _w <br /> rr <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> f 91"i. 1} absoc'bantloil/diesel/ant ifreeze� Profile �#A1y15f3384. Gloves & "G64g es , <br /> r 15. GENERATOR'SIOFFEROWS CERTIFICATION: Y hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,Arid are dass�ed,packaged l <br /> masked and Yabeledlplacafdetl,and are in all respects in proper condition for transport according to applicable intemational'andnotionol governmental regulations.If export shipment and 1 am the Primary <br /> i Exporter,I certity that the contents of this consignment conform to the terms of the attached EPAftnowledgment of Consent. <br /> I certify thatthe 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 trve <br /> GeneretorsMerofs Prints yped Name ' <br /> 5lgnature- Month Day Year <br /> _j 16,Intemation I Shnpments i <br /> j Import tc U.S.:- Export from S.. Port of entrylexiG <br /> Date tea ving U.S.: <br /> z Transporter signature(for exports only}:. <br />( 17.Transporter Acknowledgment of Receipt of Materials - ` <br /> Transporter 1 Prtntedrryped Name *.Signature Month - Day Year. <br /> Or <br /> ransporter2 rintedfTypedName <br /> Si natu <br /> CL <br /> :-.,Month Day j Year <br /> S <br /> 18.Discrepancy <br /> IBe.Discrepancy Indication Space _ quantity •. Type. El Resid ❑Partial Rejection Full Refection <br /> S .. <br /> ., <br /> ' Manifest Reference Number. <br /> 18b.Attemate Facility(or Generator} U 5 EPA ID Number <br /> tai <br /> Fad" <br /> Phone:i <br />} 1Bc.Signaturg ofAitemate Facility(or Generator) Month Day Ysar <br /> I t <br /> 19.Hazardous Waste Report Management Method Codes 4.,codas for hazardous waste treatment,disposal,and recycling systems)„ <br /> G <br /> 20.Designated cit r or.0 or.Certification of receipt of hazardous materials covers lo,,e manifestexcapt as noted in Item 18a <br />{ PrtniedlTypad Name Signature s Month Day :Year <br /> fir <br /> t EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. D SIGNATED fAC1LITYXO GENERATOR <br />