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• <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter) <br />0 <br />Form Approved. OMB No. 2D50-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />I <br />2. Page l of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 003930858 FLE <br />WASTE MANIFEST rat.000A!3 <br />869-133-9222 <br />5. GeneretorsName and Mailing Address Generators Site Address (if different than mailing address) <br />Tnterstwtsa 177 t rvhvrt Pax"PAMq, Txx <br />Asian Vallejo Ct <br />rrrenrds C4katp, CA 452,111 <br />Generators Phone;0 �nckl <br />. Transporter ompany arae <br />U.S. EPA ID Number <br />7 <br />7. Transporter 2 Company Name _ <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />Chadlresi lsste THnsgesaxat <br />35,181 Old lWylisew Road <br />Hertt.lnaawrk City, CA 93234 <br />Fadi 's Phone: <br />as. <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing If an <br />9 Grou P( Y)). <br />Quantity <br />Wt.Nol. <br />C <br />1. Roark RMA 6erenrdcn-as Viixicte, III (Oily Soli.da) <br />[ X11 <br />19 <br />-1112 <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />i -D <br />p.rajeck 1--sim +•oz : l:lTtlla2e4 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately describedabove by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are In all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I minify 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 282.27(a) (If I am a large quantity generator) or (b) if I am a small quantity generator) is true. <br />enereto S Ofieror'a Primetirryped Name tyro um <br />on any/ for <br />J <br />F <br />19. InternatioShipmentst- <br />I Import to U.S. ❑ Export from U.S.. Port of entrylexit: <br />= <br />Trans der signature for exports only): Date leaving U.S.: <br />IX <br />17 TransponerAcknowledgment of Receipt of Materials <br />¢ <br />Tm ode 1 Pnnted/Typed Name <br />tyro ure <br />�" <br />on ay Year <br />101- <br />L <br />9 <br />QT <br />iter Pn a yped Name ature <br />on ay ear <br />K <br />18. Discrepancy <br />I <br />l8a. Discrepancy Indication Space ElDor Dori ❑Type El Type <br />Partial Reactlon <br />j <br />Full Rejection <br />Manifest Reference Number: <br />18b. Aitemate Facility (or Generator) <br />U.S. EPA ID Number <br />1 <br />v <br />a <br />LL <br />Fedli 's Phone: <br />w <br />18c. Signature ofAAemale Facility (or Generator) <br />Month Day Year <br />a <br />z <br />H19, <br />Hazardous Waste Report Management Method Codes (ie., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. 3. <br />4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed(ryped Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />