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Please print or type, (Form designed for use on elite <br />UNIFORM HAZARDOUS 1. Generator Ip Numl <br />WASTE MANIFEST <br />5, Generators Name end Mailing Address <br />.,.I Er'l'b1. t'(t&N1';:''(:R I , ; jwI <br />IiGr F' ift0�'I- R6,, <br />::•"i`l(d�^ { :�a rr�tE�71_ :�: ;�ifkl.'1lY 1/31.rv:, <br />nsporter 2 Company Name <br />{?,� Yri.,'I•tNiV�:I'1l�1 Z:•�,>f":�..Cl's1;�. i.i.� <br />PAKi IQ <br />Fadli sNone: ti14S� „)37 f?,aegis <br />ga. 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (If any)) <br />f -?A l✓+ZARF. Qkr ',Mi;c..� <br />W <br />2 2. <br />W <br />c� <br />;y�F��?'t:'F��(�ir�.'I'f-: F^k? {3''�': 7'11i'F C:L=:,i;!'f•+wPtt;, <br />ki7i <br />pe I of 3. emergency Response Phone 4. <br />r9enerators Site Addreae (If different than mal <br />Form <br />address) <br />: N,i}jyti r'it:i 4104 <br />EPA ID Number <br />OMB No. 2050-0039 <br />1. JJK <br />10. conlalners 11. Total 12. Unit <br />No. Type QUentlty N1t1Vo1, 13. Waste Codes <br />I Gm 1 575 T- <br />15, UENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of chis consignment are fully and accurately described above by the proper shlpping name, and are classified, packaged, <br />marked and labeled/plecerded, and ara in all respects In proper condition for transport according to applicable intemational and national governmental regulations. it export shipment and I am the Primary <br />Exporter, l certify that the Contents of this consignment conform to the terns of the attached EPAAcknowledgr9ent of Consent <br />I certify that the waste min2mlzallon statement identhled In 40 CFR 262.27(x) (It I am a large quantity generatu� dr.(b) (Ifl am a small quantity generator)'is true. <br />Genplato el0tperors Phnted/Toed.yeme I ` 3lgnaturoMonth <br />Day You <br />16. International Shipments r <br />❑ Import to U.S. ❑ Export from U.S.' Port of enby/exit <br />— Transporter signature (for exports only), Dare leaving U.S.: <br />U 17. TransporterAcknowledgmernl of Receipt cf Materlals <br />D <br />Transporter ted(fed Name Signature Month Day Year <br />w.. ' <br />a Transporter 2 Printed/Typed Name Signature Month Dav Year <br />18. Discrepancy <br />16a. Discrepancy Indication Space El Quantity ❑ Type <br />16b. AJtsmate Facility (or Generator) <br />U <br />LC Facilitys Phone: <br />W 18c. S gnalum OfAltemale Fedllty (or Generator) <br />❑ Residue ❑ Partial Rejection <br />ID Number <br />❑ Full Rejection <br />19. Hazardous Waste Report Management Method Codes p.s.• codes for hazardous Waste treatment, disposal, and recyding systems) <br />1. 2• 3• Notice: New federal form. State of <br />California requires generator to photocopy <br />20. Designated Facility Owner or Operator. Certlficaflon of receipt of hazard0ia materials covered by the manifest except as noted In Nem 18a and mail I:O DTSC within 30 days: <br />PHntediryped Name Signature P.O. Soh 400, Sacraniento, CA 95812-0400 <br />EPA Form 6700-22 (Rev, 3-05) Previous editions are obsolete. <br />LOO In <br />GENERATOR'S INITIAL COPY <br />YVJ 2V:00 9TOZ%6Tit'0 <br />