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Please print or pe. Form designed for use on elite(12-pitch)typewriter. <br /> n ( Itch)"riter. <br /> UNIFORM HAZARDOUS 1.Generator on elite <br /> Form Approved.OMB No,20%0039 <br /> 2,Page I of 3.Emergency!I, <br /> Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators�Name and M&jfIr Address FLE <br /> U If- A� . <br /> Generators She Address(if different than-m�alling — <br /> '.A address) <br /> jv. <br /> Generators Phone..es <br /> 11-114WIVIF I UOMPanY Name <br /> U.S.EPA ID N <br /> IV umber <br /> 7.Transporter 2 Company Name <br /> U.S.LFA IU Number <br /> S.Designated—Aly Name and Site Adores <br /> U.S.EPA U Number <br /> Rliv;'Via-4 fL- <br /> '.. -, I V <br /> Fa <br /> cflhys Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(If any)) 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> 1.".;A�A'i I -.;;Ytot''3 No. Type Quantity WL/Vol. <br /> k'A i i P 0 iw, <br /> 0 <br /> < <br /> ZLLJ <br /> ul <br /> 0 <br /> 3. <br /> 14,S�-dal Handling fristrucuons and Additional Information <br /> $''t A4 wit jt-'s, 30 <br /> 15. GENERAMKS/OFFEROR'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 I am the Primary <br /> Exporter,I certily that the contents at this consignment conform to the terms of the attached EPAAcknowledgment of Consent, <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if 18m a large quantity generator)or(b)(If I am a smell quantity generator)is true. <br /> 3enerator's/Offeroes Pn-n-Oryp`97Name OKjiiature ---7e-a—r <br /> on ay <br /> 16.International Shipments <br /> D Import b U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> ui17.Transporter AcaWedgment of Receipt of Materials <br /> k <br /> Transporter I PrIntedfTypea Name <br /> cl� tilgnature -----Vc—nt I--Fa <br /> 0 <br /> Q Transporter 2 PdntWffy*Name <br /> grature onth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type EIResidue ❑Path[Rejection ElFull Rejection <br /> 1 8b.Alternate Facility(or Generator) Manifest Reference Number U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> LU 18a Ngnature OtAltemale Facility(or Generator) <br /> !Q I Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> LU <br /> 2. 3, <br /> Notice:State Of California requires <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a generator <br /> Prinieut I yped Name Signature to PhotOCOPY and Mail to DISC <br /> I within 30 day_,: <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. P-0 E30X 40(),SacraMento,CA 95812_0417 <br /> 0 <br />