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U <br />Please print or type. (Form designed for use on elite <br />UNIFORM HAZARDOUS t Generator ID Numl <br />WASTE MANIFEST cAi 4 9' <br />5, Generators Name and Maltng Address <br />az'�s'rr�� zr•►.�r�r,�rc-r�) . ;-r�arr E <br />7X27 E,:40TI-1 RD, <br />F1 Dff"}I cAArlp' <br />Generators Phone: y )R <br />8, Transporter 1 company Name <br />sN0'P (r SOLU1,K)u8I <br />k3k:iWMANt L'!)O'fv(J{ti'E3't;YVA, 3..)_C:. <br />118155 WHTE ROCK PD <br />RANCI{O +COROIWA, CA 05T42 <br />Facili es Phone: glee -3511-09W <br />ga, 9b. U,S, DOT Deacrfption (Including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if eny)) <br />1. t'ARD00SWA—STE SOLI%, <br />W <br />Z <br />W 2. <br />C9 <br />• <br />Form Approved. OMS No. 2050-0039 <br />3. Emergency ReapQh&@ Phone 4. Manifest Tracking Number <br />0� 42 4-��. JJK <br />3eneralors Site Address (if different than mailing address) <br />W Number <br />ID Number i <br />U.S. EPA ID Number i <br />10. Containers 11. Total 12. Unit. <br />Na Type Quarldty WUW, l 13: Waste Codes <br />2 0MI 88 P 3 3s2 <br />PROFILG-OR1367,s7 <br />, <br />SEF ENG #'j 71 <br />15, GENERATOR'SfOFFEROWS CERTIFICATION: I hereby declare that the mnlenln of this consignment are fully and accurately described above by the proper shipping name, andl'Iara ctesA d, packaged, <br />marked and labeled/placarded, and em in all reaped In proper condition for tranepxxt according to applicable Intemadonal and national govemmeniel regutadone. If export sh[pmeiyt and 1 an the Primary <br />Exporter, I certify that the contents of this consignmentoonfonmto The terns of the attached EPAAcknowledgn)gftt of Conseat <br />I certify that the waste. minimization statement identified In 40 CFR 262.27(x) (ff I am a large Quantity gererso) ot, ) (If I am a small quantity gene*ry Rue, <br />G�y�ato s! raPrin eOyA�ame: f/ �� r. Signature, r r Month Day Year <br />-r 16. International Stupments <br />' 1 <br />EJimport to U.S. ❑ Export from U.S. Port of entr&xlt.• <br />Transporter alynature ((or exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1^11edtfyped Name j Signature Month Day Year <br />a Transporter 2 PrintedfTyped Name Signature Month Day Year <br />18. Discrepancy <br />ISa. Discrepancy Indlcadon Space Quantity <br />16b. Altemate Facility (or Generator) <br />U <br />Facility's Phone: <br />W 16c_ Signature ofA temate FadJlty (or Generator) <br />❑ Type ❑ Residue ❑ Partial Re(eellon ❑ Full Relecdon <br />d <br />19. Hazardous Waste Report Management Method Codes (_e., codes for hezardoua waste QeglmMi,:disppsal; grid recycling systems) <br />1. 2 3- Notice: New federal foray. State of <br />California requires generator to photocopy <br />20. Designated Facility Owner or Operator. Cerllfieatlon of receipt of hazardous materials covered by the manffest except as n;;Jn item taa and mail to DTSC: within 30 days: <br />PdnteCyped Name Signature P.O. Box 400, Sacramento, CA 95812-0400 <br />EPA Form 8700.22 (Rev, 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />9001n IF3 5f:00 9TOZ/6T/VO <br />