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Please print or type.(Form designed for use on elite(12-pit(Writer.) '�✓ Form Approved.OMB No.2050-0039 <br /> T Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4.Ma fest Tracking Number <br /> UNIFORM HAZARDOUS .`r ct JJK <br /> WASTE MANIFEST <br /> 5 Generators Name and Mailing Address Generators Sile Address(it different than mailing address) <br /> Generator's Phone. <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> e.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facilft's Phone: <br /> 9a 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packin Group(8 any)) No. Type Quantity Wt.Nol. <br /> 1. -;Pi -ulml <br /> Y >D <br /> w2 <br /> FOR RECYCLING/TREATMENT AT THE --- <br /> OeMENNO/KERDOON FACILITY IN COMPIN, <br /> 3. CALIFORNIA.THIS FACILITY HAS THE RECESSARY <br /> PERMITS TO RECEIVE YOUR VMW STREAM AS <br /> 4 <br /> 14 S�dcial Handr In,l,,,lons and Addrtlonal Information u {.r+�� , -R <br /> Wi. 9 -. 24 HOUP EMERGEPit; G�1Ehf(PEC 800-44�'7�AP40 CHICO' DF,14141 CIA SEE 'JICE <br /> SCni-; . .;.'i <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 labeled/placarded,and are In all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and 1 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 statenpqnt identified In 40 CFR 262.27(a)(g 1 am a large quantity generator)or(b)(if I am a small quaA generator)is We. <br /> Generetor'slOfferors Printed/Typed Name Signa a Month Day Year <br /> %, r'6 O <br /> 16.International Shipments <br /> F Impoto .S.rt ❑Export from U.S. Port of entry/exlC <br /> z Transporter signature(for exports only): Data leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedoryped Name Signature /' Month Day Year <br /> A - , <br /> Transporter 2 Printed/Typed Name -" Signature Month Day Year <br /> C <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parbal Rejeotion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aternate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> ra+. Facility's Phone. <br /> 18c.Signature of Allernatn Facihly(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 1. 2. 3. 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 /> nntedRypod Name Signature r-' Month Day Year <br /> EPA orm 8700-22(Rev.3-05) Previous editions are obsolete. I !' E IGNATED FACILITY TO GENERATOR <br />