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i <br />"a <br />fForm designed for use oaeRefl2-latdrl tvcewriter l <br />Form Aooroved. OMB No. 2050.0039 <br />NIFORM HAZARDOUS <br />'-Geom"rowd0eir <br />2. Page 1 of3. <br />Emergency Responseifest Phone <br />424"9"AOO <br />ManTracking Number <br />014053070 K' <br />WASTE MANIFEST <br />C&3>008277036 <br />(SM- <br />JJ <br />S. Generator's Name and M Address Generators Site Address (ff different than nmlmg address) <br />ASSWRY E 1�lfFAL $El iuS <br />:t:W S. :�_ fE AVE <br />CA <br />310 AA6-34 i0 <br />fieneralors Phone: _ <br />(i Trans ": 'D DI e: <br />U.S. EPA ID Number <br />, . <br />=,, � ��Gi,MENTAi CESS <br />(: A 1) 0 2 8 2` 7 J} 3 6 <br />i.TaapArr2CE�raperryName ; <br />I <br />U.S EPA ID Number <br />Dfignated Fadldy Name and Site Address ., r . , <br />" alkTt"Jr tP ?#ttPd: I -M. <br />U.S. EPA ID Number <br />-�4T-•E+���'i�tt�l�itttC�-�.rE �r� Itg t� a;, ."" , :� o � , <br />— _ . <br />Fa s Phone: 06R)498-02-40 <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if arry)) <br />Quantity <br />WtNol_ <br />1" NO K .ilR'O:. IS WE, IJQW ED Ott / MIXED OALi <br />1 <br />001 <br />TT <br />U.1 <br />W <br />i <br />I <br />3. <br />i <br />4- <br />; <br />i <br />t <br />14. Specal Handfing Instrunons and Add—O" In aeon <br />EMERGENCY G(WTACT " ClfF A.TREC i iJi} d24 JG ' ApPP, :PF(iA7E PFR' Wfik P f JEC- t1YE <br />F--;' QF`,4 N: i ' E MSF ,, Nr , <br />?�-MTACT CHFUTREC WO 424 9'3XA) k Ti?ik:�:� <br />15. GENERATOR'SIOFFEROR'S CERTIFICATIO : 1 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 labeledlpfacarded. 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 consiiinment conform to the terns of the attached EPAAduwwledgment of Consent <br />I certify that the waste minimization statement' ntified in 40 CFR 26227(a) (41 am a large quantity generator) or (b) (41 am a small quantity generator) is We. <br />GeneratoNCrffeetors PrintedjTyped Name Signature <br />Month Day Year <br />_r 16. International Shipments r� <br />[I.--''- <br />Import to S. uExportfrom U.S. Portnfentrylexh: <br />'Date <br />Transporter signature (for exports only): leaving U.S.: <br />W 17. Transporter Acknowledgment of Receipt of Materials <br />Tratrsporter 1 Printed Typed Name <br />Signature, <br />Month Day Year <br />IL <br />za Transporter 2 P4ntedflyped Name <br />} Signature <br />Month Day Year <br />< <br />r <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quan <br />❑ Type ❑ Residue <br />❑ Pa1ial Resection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Faality (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />U- Facie} s Phone: <br />w 18c. Signature of Altemate FacrTAy (or Generator) <br />Myth Day Year <br />a <br />Z <br />19. Hazardous Waste Report Management Method es (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />N <br />LU 1. 2.3. <br />4. <br />20. Designated Facilay Owner or Operator Cerlfiicalion of receipt of hazardous materials coverr i by the manifest except as noted in Item 18a <br />Prinledlrypcd Name Signature <br />Month Day Year <br />EPA f=orm 8700-22 (Rev. 3-05) Prevkxus editions Are obsolete. <br />GENERATOR'S INITIAL COPY <br />