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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M n st rackin Npu <br /> WASTE MANIFEST FLE <br /> 5.Generator's Name and Mailing A s5 "'`" `'`"' Generator' to fires"(If diffefe Tf than mailing address) <br /> Port of Star*ton <br /> 2,C3# L'f hivtf)irs-t 1�1't . <br /> t #may C A'95201 <br /> 6.Transporter 1 Co np bye.. „r;M <br /> ldtdNs!"Iced+e.iFlenw.c c�1a4'st7II�!3G. i 'pf <br /> 7.Transporter 2 Company Name UL 1 7 2017 <br /> waii;3M&t -p@GG4F:7't` .r�FiLC<iY'J, 3f IW <br /> 8.Designated Facility Name and Site Address <br /> ENVIRONMENTAL HEALTH <br /> '30 F. 13s,StDEPARTMENT <br /> Facility's Phone: s g 4 X <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> 11,ki @-T .RA 1 e1.>*eiC4�::l;!.ifi Y`;1�16i:.a�k':,'�ir.e��ti.'�.(OR';So ftx:) <br /> O <br /> LU Nctit-MCRA flay�rrdom:s lays r�,F.iquiti3, (c:4 fflwa 11cs9,crot lted G`v1 723 <br /> n tic tuft: t aB�:ltnt 3> dasa � <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> j 1 im PO r; <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby eclare that the contents of this consignment are fully and accurately descr <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable interna' <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) <br /> enerators/0 eroes PrintedrTyped Name bignature <br /> AC <br /> J 16.International Shipments <br /> Z ❑Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/Typed Name Signature, <br /> N i Y d til L. <br /> ZTransporter 2 Printed/ryped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ElType El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> r 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> V <br /> Q <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. <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/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />