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Please print or type.(Form designed for use on elite(12-pitci writer.) Form Approved.OMB No,2050-0039 <br /> UNIFO„ HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phon, 4.Manifest Tracking Number <br /> W, (�c MANIFEST 7 003567631 JJ K <br /> 5 ,Iheratoes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Mica 9t�IBb1 <br /> 2769u0nAVIIII" <br /> MV CA WIN <br /> Generator's Phone: <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company ame <br /> C8ftMW ET1V'k'Oflflll --8r LNb ��� <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 6kw*m WdK TedWK*4 N C0M- CAD097030M <br /> 5375 S.eoMftAVW b <br /> Loswnqas,CA OM <br /> Facilitys Phone: 3M 2 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ga. and Packing Group( any)) No Type Quantity Wt.Nol. <br /> HM (if <br /> 1. lir*canterr kNftd debrk) <br /> 352 <br /> o Non IZC3tA lie¢aldt�us,Nas�e.Said fws� 001 � �� P <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> e.W gSW debris,onsbc Wckels,corft*tlWWd VAb"* 036705TX171 <br /> y � 1v <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are and accurately described above by the proper shipping name,m d 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 certify that the contents of this consignment conform to the terms of the ajtached EPA Acknowledgment 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. MondDa� Ye <br /> Generator' Ofteror's Printed(Typed Name Signat e (/J� <br /> l 4W <br /> F <br /> 16.Intern tional Shipments Import to U.S. <br /> Z Export from U.S. Port of enlrylexit: <br /> _ D leaving U.S.: <br /> Transporter signature(for exports only): <br /> J 17.TransporterAcknowledgment of Receipt of Materials Month DaYeas_ <br /> cr_ TransportPePrintF ended Name Signature U O(v,� <br /> O <br /> cn onCh Day Year <br /> Z Trans r 2 Printed/Typed Name atur O C O <br /> < _ ���e C L <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity <br /> ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Altemate Facility(or Generator) <br /> J_ <br /> V <br /> tai Facility's Phone: Month Day Year <br /> W 18c.Signature of Altemate Facility(or Generator) <br /> Q <br /> Z <br /> O 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> co 1 2. 3. <br /> 4. <br /> D ' <br /> w <br /> 20.Designal Facility ner Aerator:Certification of recei f hazardous m rials covered by the manifest except as noted in Item 1 Month Day Year <br /> Printed/Typed Name Signature <br /> r <br /> EPA Form 8700 22(Rev.3 05 revious a itions are obs e DESIGNATE ILITY T TINATION STATE(IF REQUIRED) <br />