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IN <br />4 <br />Please prig— or type: (Form designed for use on elite (12- <br />UNIFORM HAZARDOUS 1'"� ID Number <br />WASTE MANIFEST t� 1�` i `' `i1 a <br />rypewr ter.) Form Approved. OMB No. 2050-0038 <br />z page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />Via) "�4'y tCt Fn S �in JJK <br />5. Generator's Name and Mailing Address ' <br />Ll 1.�-L.tilJlt� ii jJC;I <br />{( 3 \ i� 21 IJO- QA fit � � i.4, . <br />bene td>'s Piton: J <br />6, Transporter 1 Company Name <br />A <br />Y , <br />faci Is Phone: <br />9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number <br />HM and Packing Group (if any)) ` <br />a <br />UJ 2. THIS MSTE STREAM HAS BEEN QUALIFIED <br />FOR RECYCLING/TREATMENT AT THE <br />+ FAe IUf Y 1IC. 0I` t <br />3. CALIFORNIA. THIS FACILITY HAS THE NECESSAR'i <br />PERMITS TO RECEIVE YOUR WASTE STREAM <br />4. MAUREa OURPA NUMBER IS CAT080013352. <br />4 z '7 7 0 <br />ID <br />10. Containers 11. Total 12. Unit 13. Waste Godes <br />No. Type Quantity Wtivol. <br />14.SpeaInformation .NdandlinInsWinfi�(=3 f',(t <br />g Gi / o 74 <br />ed, packaged, <br />of this consignment <br />ntemationa and naboonna governmental regbed above by the ulations.per Ishipping port shipment and i am the Primary <br />15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the <br />r traentsnsport applicable <br />marked and are in all respects N proper condition for 7ansPort <br />and abeled/Placarded, Consent Ia small quant ry genarator) is true. <br />Exporter, I cer* that the contents of this consignment conform to ans terms of the attached EPAAcknoWleddgm - tt Of <br />40 CFR 262.27(a) (if I am a large quantity generator) () ( <br />Year <br />I certify that the waste minimization statement identified in <br />Month Day <br />Signature -�''� <br />Generator's/Offeror's Printed/Typed Name *7,,--. ! `lo; <br />r: L <br />I/ey.109 <br />l 1. <br />J <br />16. International Shipments ❑ ❑ Export from U.S. Port of entrylexik <br />Import to U.S. <br />I= <br />> Date leaving U.S.. <br />z <br />-ransporte. r signature (for exports arty): <br />17. Transporter Acknowledgment of Receipt of Materials <br />Month Day fear <br />� <br />Signature <br />T•ansporer 1 PnntedlTf* Name z <br />r �r- <br /># _i <br />Month Day Year <br />QT-anspoler2Printewiyped <br />Ntame <br />t- <br />19 Disc epancy <br />I Residue ElParlial Rejection <br />E] Full Rejection <br />16x. Disaepa" indication Space El Quantity Type <br />Manifest Reference Number <br />r <br />U S. EPA. iD Number <br />%" <br />195. A1ter"afe Faatity for Generator} <br />J <br />U <br />tai. <br />Fsafity's Phoria: <br />Monti! Day fear <br />! w <br />+, ac, Signature of Alternate racr6ty ( or Gerertor} <br />lQ <br />C.7 <br />•g "1az?1d0uS':,�asxe Report ,�'tanagern9r+ Method Codes j�.e-. codes for hazardous Waste treatinent, disposal , ar fit re:ytiIn- 5 e"ns, <br />6 <br />LU <br />2. <br />20. Designated FaoUty Owner or Operator: Certification of recut of hazardous materials ,mv-wed 5) the manrfest except as nulled m tem i9a <br />" <br />tdarth Day Year <br />^. <br />� JRJFlatlrre r <br />DESIGNATED <br />FACILITY'S COPY <br />EPA Form 8700-22 ,. ev. 3 05) Previous adi6 s arevitop113fa. <br />