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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.Manifest Tracking Number
<br /> WASTE MANIFEST (' 7t j, ft t) 3 '�'r s s a
<br /> :3 5 4 7 �- � i (R4ili?�:?4-�:3�� ��`� E �� :� J J K
<br /> 5.Generator's Name�and Maiiing Address Generator's Site Address(d different than mailing address)
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<br /> M ROX 1014=6 "MVTi,7,R; `IN :379;i9 FT", CA Ca Fit,
<br /> Generator's Phone: ( 615,) 588"74&3
<br /> 6.Transporter i Company Name U.S.EPA ID Number
<br /> ,-ArJF0PNTA. NA AF?i3C IS `9RVTC:FS CAR0002.0W12:3
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number;
<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> CT'{'7m,hi ..,v P OVPT-I-nrl, Ti`tn.
<br /> y: .) W, 171,.h S#-. [d)na F6?arh, Ca_ 90R13 CAD028409019
<br /> Facility's Phone: ("169 432--54457.3 Y
<br /> ga 9b.U.S.DOT Descripfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit
<br /> HM and Packing Group(if any)) No. Type Quantity WtNlo13.Waste Codes
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<br /> 4. it 14"i'V F 8 i
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<br /> 14:Special Handling Instructions and Additional InformationAu loll Z�
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<br /> j€T.j, r"t ('14L-3ikt^, i4RWjR9C: -- 900-A24-9310
<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 labeledlplacarded,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 terns of the attached EPA Acknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.
<br /> Generatorsl0lferorsPrinter d/TypedNam6 Signature Month Day Year
<br /> .� 16.International Shipments 3a
<br /> 0 2. 1 t
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<br /> 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit:
<br /> z Transporter signature(for exports only): Date leaving U.S.:
<br /> 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printed/Typed Name Signa Month D/ay Year
<br /> Z Transporter 2 Printed/Typed Name SignatureMonth Day Year
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space Quantity ❑Type El Residue El Partial Rej
<br /> ectiom Full Rejection
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<br /> VN5 s# ferarce Number:
<br /> 18b.Alternate Facility Ee r0 tfd Ry!Z' pSN,k3t1>ra3y7 gtr 7gy�trr �e ` U.S.EPA ID Number
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<br /> J �T7?kY'3T�k5ld6dcllfGbl.FR01P•l.'fIt)N�F,�„CY �,,AF.C ?'1C� -}FtTi,�„'a�' j3�`r'
<br /> <% 10(�C011SMAT1014 Atm'RECOMY ACT OF 10r 6
<br /> rQi Facility's Phone: VW-MALfl REW" 10NS,.CR.,=y k E;4)1111 'AIL of
<br /> w 18c.Signature of Alter 11 r� or �FtG�1r Month Day Year
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<br /> y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recyclirg systems)
<br /> G1. 9 s 2. t �.. 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 /> Pnnt iT�ped Name . Signature Month Dai Year
<br /> 7(1
<br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR
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