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<br />Form Annrnved. OMB No. 2050-0039
<br />EPA Form 8700-22 (Rev. 3-0b) Hrevlous e0itiofls are oosolete j
<br />VYyy;7tr ..<N. - a q�xn" TRANSPORTER'S COPY
<br />UNIFORM HAZARDOUS
<br />1.,Generator ID Number r
<br />2. Page 1 of
<br />3. Emergency Rtesponse Phone
<br />4. Manifest Tracking Number R
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<br />WASTE MANIFEST
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<br />1
<br />"424-0
<br />30
<br />5. Generators Name and Mailing Address noaiu fnomy.IfG I,:noi1 r;airGeneratora Site Address (if different than mailing address)
<br />PVC)FLELT,1K, " LODi ROAD TH 2)rafittttcl 1rut;;;1s d ;
<br />154x553 N- C}t4�ITCNr1
<br />606p ELKi+#C)ilir JtfA'1 i L(O CA i
<br />ELK GRO�M, CA 1 .
<br />Generators Phone: 3G wrtilu 8m molly bA6 F'tb)#X810' f fOQ'9ft11QIna t is xod.J1001 aft *tarso MUM 19h0gxq �0& nr• 01
<br />6. Transporter 1 dmpahy am9 '' U5E1PAID Number -
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<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />7.
<br />8, Designated Facility Name and Site Ad ess r ' " "" U S EPA ID Number
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<br />Facility's Phone: ,..
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<br />9b. U.S. DOT Description (Including` Proper Shipping Name, a�yrd(`lass, nf1 fNlu tMw
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<br />,:,10, Containers ,W.
<br />11 Totel�rtr
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<br />Z .,Unit,
<br />„i,,;,, 13. Waste Codes
<br />No,
<br />Type .
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<br />and Packing Group (if any)) .
<br />Quantity
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<br />14. Special Handling Instructions and Additional Information
<br />t INKS To 1M 4D "OUR
<br />9btj 145+55 5 '.. 40 I i
<br />15. GEN ERATOR'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 labeled/placardod, and are in all respects Inpropej 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 consignmentconform to the terms of the attached EPAAdcnowledgment of Consent.
<br />I cert fly that the waste minimization statement Identified In 4C1CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Ge ratorslOfferors Pn ted(Typed Name Signature r .j r . ;r. Month Day Year
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<br />r 16. International Shipments ❑ Import to U.S,
<br />❑ Export from U.S. Port of entrylexit:
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<br />Transporter signature (for exports only):
<br />Date leaving U.S.:
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<br />17. Transporter Acknovviedgment fReceipt of Materials
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<br />er 1 Print
<br />Trams
<br />Month Day Year
<br />Signature
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<br />ransporter 2 rinted(fype ame ,
<br />Sfg)ature . Month Day Year
<br />18. Discrepancy j
<br />18a. Discrepancy Indication Space ❑ Quantity
<br />❑ Type ❑ Residue Partial Rejection ❑ Full Rejection
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<br />Manifest Reference Number:
<br />18b. Alternate Facility (or Generatgr)
<br />U.S. EPA ID Number
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<br />aFacility's Phone: .
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<br />18c. Signature of Alternate Facility (or Generator)
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<br />Month Day Day Year
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<br />19. Hazardous Waste Report Management Method Codes (.e., codes
<br />for hazardous waste treatment, disposal, and recycling systems)
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<br />1 �•4.- �1
<br />2. I''
<br />3
<br />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 />Pninted(Typed Name Signature Month Da Year
<br />EPA Form 8700-22 (Rev. 3-0b) Hrevlous e0itiofls are oosolete j
<br />VYyy;7tr ..<N. - a q�xn" TRANSPORTER'S COPY
<br />
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