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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> 1 F-orm Approved.OMB No,20%0039 <br /> UNIFORM HAZARDOUS .Generator ID Number 2.Page 1 of 3.Emergei c), esponse PhoneManifest Tracking Number <br /> WASTE MANIFEST J <br /> me and Mailing Address PLE <br /> IL 0 <br /> 5.Generators Na <br /> ling <br /> res if different than mailing address; <br /> A <br /> Generators Phone::,., Mkt <br /> 6.Transporter I Cvwpany Name <br /> U.S.EPA 1L)Number <br /> f.Transporter 2 Company Name <br /> U.S.EPA 10 Number <br /> $-Designated FacilitylUffleaflCONA(li <br /> U.S.EPA It)Number <br /> ;V <br /> Fadirty's Phone. <br /> 9a. 913-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 <br /> ott';4V,1-k' No. Type Quantity WtNol. 13.Waste Codes, <br /> LLJ <br /> W <br /> 0 <br /> 4, <br /> P <br /> 14.Spatial Handling dling In5L uGuonsandAdartionalInformallon EN IR <br /> , ," <br /> -4 60A 0 r. <br /> ENT <br /> v4'1 VQ0 i f"rr <br /> 150 GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classlii;j,—p—a.kg.d, <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 certify that the contents of this consignment conform to the terms of the attached EPA AdmWedgment of Consent <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)V I am a large quantity generator)or(b)(If I am a small quan*generator)is true. <br /> Ivionm L)ay Year <br /> ❑ <br /> Zi 16.Intern Shipments <br /> I-- Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature for exports only): Date leaving U.S: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Tnansp—ort-571—Rn—wayped Name MSignature <br /> 0 ayearonth <br /> co <br /> Transporter2 PrInt0d1TyWd Name <br /> Signature montin Cay Year <br /> 18.Discrepancy I . I <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rei ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Man'rfest Reference Number: <br /> —J U.S.EPA ID Number <br /> 0 <br /> Facil <br /> LLJ 18c.Signature of Alternate <br /> Q ' Month DayYear <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment disposal,and recydingsyste.ms) <br /> LLJ —1 <br /> 2. 3.F <br /> T—A-- <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous—materials covered by the manifest exNotice:State Of California requires <br /> cept as noted In Item 18a generator to Pho <br /> Pgt—edrrypedNeme S gnature tOcOPY and Mail to DTSC <br /> " I <br /> within 30 days: <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. P-0 BOX 400,SacramentoCA 95812.0400 <br />