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Ir <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB Nlo.2050-0039 <br /> 11IFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.IAnnifesst Tracking Number umber <br /> WASTE MANIFE (� B 1AS q 00341-1814110 JNU <br /> Genea5.Generators Name andMailing Address tors <br /> She Adilres"s(I(different Than mailing address) <br /> Generator's Phone' f',91-3 4 "`/-1©0'3 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ENVIRONIVIFINffAL LOGISTICS, IINC CAR000217.513 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Desi paled ffacilil Na and Site Address U,S.EPA 10 Number <br /> FPLfEI�RFyC'1LIfJG�E�VICES, INC. <br /> 180 WEST rvIGNTE AVENUE [:P,.ngR?tacnRl <br /> RIALTO,CA 92316 USA <br /> Facility's Phone: 800-698-4377 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> 13.Waste Codas <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> 9 ( J <br /> LLI <br /> LU 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information ®�Z7 <br /> 9[31)�l �L /��/ � �VLARA111PROPRIA-I-EPPE IrJ1y.4d'tZ�� <br /> 9132) <br /> 9E,3i <br /> UIjr1 <br /> 15, GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare[hal 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.4 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 Acknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am a large quantify generator)or(b)(!fLqmk4l quantity genera r)is true. <br /> Generale's/Off rors PrintedlTyped Name � Signature ® O Month Day Year <br /> -5 iv 6�'rJS� <br /> nternalional Shipments <br /> r— ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> z Transporter signature(tor exports only): Dale leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of alerials <br /> Tra porter 1 PrinI dlT ped ame Signatur Month Day Year <br /> a <br /> Q Transporter 2 Pri led yped Name Signature Month Day Year <br /> 7K <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Relecfion <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> Z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU ,. �� 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 1 B <br /> Prinled/fyped Name Signature o Ih Day Yee 13 ar <br /> EPA Form 8700-22(Rev.3-05) Previouis editions are obsolete. DE 9GNA11 EI7 FmILI T Y ICS©CSIINATION STA E(IF REQUIRED) <br />