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Please,;)'nt or type..(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAHI I 10006W 80042+Q" 1010387123 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,q,*rt KT0N SAM-ING,SAM-IFC;t_IIA Imo, <br /> ;l OCC! Edi,.CA 46 2ig <br /> Generator's Phone: 2f.h)-9512- C1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> irt4VI 2r V AE-NTA 11(X3t-STI S, iTtC CAf4)V)2 t'l <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DFeEt f�FMi:Yaf^� it�� f E t�L. U.S.EPA ID Number <br /> R lAi TO.CA l+►,310s USA <br /> Facility's Phone: IMO-PAq,a 4377 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. !'Jt`°fiCRA HAZARDC',LIS F301..40(ABSOR RBEa<T€,AO . 1 1 Fy is <br /> o Ct '4T'�+fv�It�At-ED VVIO 1.� ` <br /> W <br /> -z- - <br /> W = - <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1 f B,"* FT41'PA08 C,1..#4'3"AMI NATE t.)'WK ff..�*k�y6�: .ry ,,� q vpp .AR,fi,FyPROP fR(ATt"PPF, 41 11189-IN <br /> EM15-RoE::P,W�,t��f?FSPCq6'��� �'`�'��`.�AM411F.0 9a�fCA-�l+,Q^t,9',,f_4f1 <br /> 15. GENERATOR'S/OFFEROR'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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 9 CFR 262.27(a)(if I am a large quantity generator)or(b)('rf I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name a Signature Month Da Year <br /> 7 l - <br /> .i 16.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transported Printed/Typed Name I Signatu Month Day Year <br /> N <br /> zQ Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space <br /> ❑ Quantity El Type 1:1 Residue ❑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 /> UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. 2. 3. 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />