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IDI.— —int — t—. ir:— dihcirinairrl fpr imp nn -.lil (19-nittnewrl 8 Form Approved. OMB No. 2050-0039 <br />EPA Form 870022 (Rev. 3-05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />UNIFCRM HAZA�RDOUS v <br />1. ID Number <br />Generator <br />Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />12. <br />71 B F <br />5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address} <br />i Io I If i 1 <br />Generalor's ftew: - 6e, <br />6. 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 Address4( H� U.S EPA ID Number <br />f <br />Facility's Phone: <br />92, <br />91 U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10 Containers <br />11. Total <br />12. Unit <br />HIM <br />and Paalng Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />Ir <br />0 <br />2. <br />LL] <br />-f <br />14 Secial Handling instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelecUplacarded, and are in all respects in proper condition for transport according to applicable intematonal and national governmental 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 attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (41 am a small quantity generator) is true, <br />V <br />Generator's/Offeror's PrintedlTyped Name Signature Month Day Year <br />I I I I <br />=-J <br />16 International Shipments <br />El import to U.S. ❑ Export from U.S. Port of entrylext: <br />Transporter signature (for exports only): Date leaving U.S,: <br />L= <br />U <br />17. TransportarAcknowtedgment of Receipt of Materials <br />F4 <br />TransP9 PriniiedrrypLd Name Signature -f Month Day Year <br />0 <br />i <br />cc <br />Transporter 2 PrintedfTyped Name Signature Month`Uay Year <br />rr <br />18, Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />I= <br />18b. Aternate Facility (or Generator) U.S. EPA I D Number <br />Phone: <br />eQi <br />Lill <br />Facility's <br />18c. Signature of AJtemate Facility (or Generator) Month Day Year <br />Z <br />0 <br />19. Hazardous Waste Report Management Method Codes (he,, codes for hazardous waste treatment, disposal, and recycling systems) <br />Fn <br />W <br />0 <br />1 2. Notice: New federal form. State of <br />California requires t'oenerator to photocopy <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a. and mail to DTSC within 30 days: <br />Signature P.O. Box 400, Sacramento, CA 95812-0400 <br />Prirtedfryped Name <br />EPA Form 870022 (Rev. 3-05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />