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Please orintortype.(Form designed for useon elite(12-pitch)typewriter,) Form Approved.OMB No.2050-O039 <br /> O <br /> UNIFORM HAZARDOUS 17 <br /> Generator ID Number 2.P;F7f <br /> Emergency Response Phone 4.Manifest Tracking Number <br /> C�'en <br /> WASTE MANIFEST GBF <br /> U <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Jr: <br /> Th <br /> Generator's phone <br /> 6.Transporter I Company Name I IBM 144AM ID Number <br /> 7.Transporter 2 Company Name DEC 15 2009 U.S.EPA ID Number <br /> 8.Designated Faclifty Name and Site Address U.S.EPA ID Number <br /> 'OUNIl <br /> SAN JOAQU.N C <br /> ENVIRICINM., <br /> iTAL <br /> HE-4ki-TH DEPAR'MENT <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(Inc uding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(luny)) No. Type Quantity 1A Vol. <br /> 0 <br /> ru <br /> 3. <br /> 4. <br /> I A 1-1 �Mr0pric,166 i <br /> t <br /> P <br /> permill. forand wit act .,f <br /> 14 <br /> 14 Special Handling Instructions and Additional Information -14M wdstu L I rat <br /> shipping. <br /> 15. GENERAMR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of I-lis oo-isignment are fully and accurately described above by the proper shlipping name,and are classified.packaged, <br /> market and labeled/placarded,and are in all respects in proper condition for transport according to appiicable international and national gavernmenial regulations.If export sh pment and I arr the Primary <br /> Exporter,I certify that the cotters of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste niinimimlion statement identified in 40 CFR 262.27(a)(if I arr.a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorsfOfferoet Pfinted/Typld NameY Month Day Year <br /> -J 16.International Shipments <br /> Import to U.S. Ej Export from J Port of entrylexii: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LJJ 17 TranspareTAcknowledgmentoi Receipt of Materials <br /> Transporter-Pn"TrypedName Sianatuyl Month Day Yaar <br /> 4 <br /> -V r <br /> 00 V tr9l. <br /> Transporter 2 Printed!-yped Name' S@rkkre 'Month 08y- Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 C.,fity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> >- U.S.EPA ID Number <br /> 18b.Ahemate Facility-'or Generator) <br /> Facility's Phone: <br /> C3 <br /> Lui 18c.Signature clAfter-we Facility(or Generator) Month Day Year <br /> inin 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and re-,ycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner orOperator:Certification a:receipt of hazardous ma-.erials covered by the manifest except as noted in Item 18a <br /> PrintedfFyped Name Signature Month Day. Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACM d <br /> -M <br /> .7M <br /> C966-9Lt-60Z eJ19AJ!S nod 8ZV:L L 60 9 6 090 <br />