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Plicas rJ';,pe (Fgrm designed for,use on elite(12-pitch)lypevvriter.), Form Approved.OMB No.2050-0039 i <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2Pagetor 3.Emergency Response Phone 4 ManffestTmcking Number j <br /> WSTEMAIFEST ) `:1 <br /> d_ n >I '.(° <br /> JJK <br /> -RIerator's Name and Me ling AddreSs <br /> General SdeAddress(ffdifferent than mailing address) <br /> lq` ¢: <br /> i c:'etvd fd—iveJ Ssr'"..r.MV,4aji, <br /> Generators Phone: r '+y' , � cwt/'• 4 L fi ri"c. t(C;.- CA <br /> 6.Transporter i Company Name a )1 S EPA ID NPmber _ <br /> ii- <br /> 7.Transporter 2Company Name U.S.EPAID Number r <br /> 8.Designated FaC6ity Name and Site Address U.S.EPA ID Number <br /> .,^ r ,G�•4� fs•v�r�. .part:' _ I <br /> 'r4Gr ,t^-.� �G'$° 6, �' ^x` SmLws Gt'si#.a'- C.A.% `—d (�0q p <br /> Fadhys Phone: f` „7'� ` �;.'f e tel..' 4� c ya L ✓}�i Q�+' <br /> ga. 9h.U.S.D0T Desorption(mdudng Proper Shipping Name,Hazard Class,ID Number, iD.Containers <br /> HM and Packing Group(if any)) 11.Total - 12 Un8 13.Waste Codes <br /> No. Type Quantity WWI. <br /> 1 a u� "'..Y'$ q { <br /> s <br /> W 2 A,l..� 1A.D�1,;,T�C4IAe°d[i YS✓Y�r,� m 4�0.�®..r y r: G+Wy�' oh® <br /> c7 <br /> 3. <br /> n@ REFERENCED WASTE WAS RECEJV D.H W)LED NO SroMa POR SUaSEQ 111E I <br /> ASVOSAL,TREATMENT OR REUSE CRO Bl A OVIRCTO'.INC OR TES TRE FA Or <br /> �I.NRS CAtA[W TO TIMM.BY TIELA RARTMENT OF PDXIC SUR ANCE W TOM Eli <br /> 4. HE RESOURCE CONSERVATION AND I ECOVERY A OF 1976 W APPLIC BU <br /> IEDERAL AND STATE REGULATIONS. MOSBY ! O ERTON ALL OF NECFSS .Y <br /> PERMITS TO ACCEFT TWE WASTE AND ALL T1W ASTE NAS IS JJANE LED <br /> ACCORDNW.Y <br /> eaal Handling lnsqulions and Additional Info n <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 /> 'uarked and labeled/placarded,and are in all respects in proper candfion 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 consignment conform to the terms I the attached EPAAckroWedgrtrenpf Consent .F <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)pr(b)(if I am a smell quantity generator)is true. <br /> Generatofs/O6erefs Printed/Typed NaTe a Signature - Month Day Year <br /> P t."l ,Z n1 e ke �\� '✓e'' � 1111,;.. � f � %;�:.- � � � � ! <br /> =j 15 Imeinlitional Shipments <br /> 1 <br /> ❑import m U.S. ❑Ev7wrt 6om U.S. Pod lerntryledt <br /> = Transporter signature(for exports only): Date leaving U.S.: I <br /> Of 17.TransporterAdeowledgmem of Receipt of Mat"Is <br /> T spmrterl PdntedrTyped Sig re \ Month Day Year I <br /> 0 Le <br /> fransporter2 Pnnte]dName ,St9naEnre MoMI Day Year <br /> r I <br /> 18.Discrepancy { <br /> I <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑TYPe ❑Residue ❑Partial Rejection ❑Full Rejection j <br /> Manifest ReferenceNumber. <br /> IBb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facilhys Phone: <br /> W <br /> .Day <br /> Q I <br /> 2 <br /> • ^" `+azardous Waste RepalManagement Meawd Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> ! S I <br /> 20.Designated Facility Owner sir .OpemWr.Cerlifica6 rpt of hazardous materials covered by the marifestezcepLaS�iwled in Item tBa 'j <br /> PmrWyped Namesgnaaee "O Mono Day Year { <br /> '4L2' m <br /> L �� f <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR j <br />