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r . <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest{Trackln�Nuumber <br /> , � : JJK <br /> WASTE MANIFEST t:��k."�.)i1_f���"��� !`��)�..$ �, r9 }: �»�1� �E'�91..1; �� .J,Y.,•� r 4 <br /> 5.Generator's Name and Melling Address Generator's Site Address(if different than mailing address) <br /> jhe��.lcP71:11'1.1 ROAD �l•,�'e.�d'.'.i.� °�':��a{lii�.t A"��',�_%"ill?S. <br /> 72AC ', 4'A 9s.';1116 E:r'AT'X!''20) Rivb 3e <br /> Generator's Phone: 9f s f i<- ;r�:it3 i� .�:Tn:S �1>3.t f i:.'F:e 9,f.ad lt,.f•9ki "s""a!E i'.`:' Q:: qt:'r d) <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <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 /> CDMIX-PE CA 50222 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantity X/Vol. <br /> 1. <br /> o xAIaFs0 <br /> ?'ri+'1«tiik`:I.+ �71r�`#$ ."".'4�lti�: 3t N•aRf�tla:lt'�P3r; $!i} ,�. °m;. .� � ��-U <br /> Z 2. <br /> LU <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> A ITKIND LTE !X.Aq-V'Rti"T 3; 51VER f'tllluf fell 6YDVF.a ERG 128 <br /> Ta? �if3?: 'e$s$Sf�A Sa SQUIN CM-STRIfiT?£ON, IN. lArikvk"3t ETt?e' F1' `P't°+� ;e Fard3i�:: <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 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 certily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 /> Generator'slOfferor's Pdntedlryped Name Signature Month Day Year <br /> rCc Ci G ✓ 2 <br /> -r 16.International Shipments i 'ckw\ ❑ ort from US• Port of ent lexit.• <br /> ❑Import to U.S. P ry <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> I`-; Transporter 1 PdnledlTypetl Name Signatures f; Month Day Year <br /> Z Transporter 2 Printed/Typed Namd Sigdature' Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ElType ElResidue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL. Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> Y) 19.Hazardous Waste Report Management Method Codes CO.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2 3• 4. <br /> 20,Designated Facility Owner or Operator:Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed erne Signature Month Day Year <br /> c 11 ; <br /> EPA Form 8700-22 1Rhv.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> A0`04.iR'c <br />