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71 4c" <br /> Please print or type.(F I orm designed for use on elite(12-pity—,Typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of Emergency Response Phone Manifest Tracking Number <br /> WASTE MANIFEST 0028-J. 0 ,)96 SKS_ <br /> 5.Generator's rator's Name and Mailing Address Generator's Site s(if different than mailing address) <br /> NF <br /> CA 13521.5 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number 0 10 0 0 0 F)3 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U,�EPA ID Number <br /> SAFI: <br /> TY­KLIKEN SYSTEMS, '6'W_. <br /> .N'1CRAMENTfl <br /> Facility's Phone: -• <br /> A 1 <br /> 6 4 5 <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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> NUNI RC RA 1-1 0 9,00iP,3 listA"O I W <br /> 0 1 L AND Ti­E R <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> SK S H 1 P#205 1 55,;;F.7 5, 5 1 6'i'.A <br /> 24 HR EMERGENCY #1—A0@--4(­8—t7i5-0 (SAFETY-4<1 EF.4 — I t-4 In A <br /> CO R 1 3'3 <br /> C',V Q 1144n P,1-j f�`F', 1-i'I 191W;', r,,T T--PC-.-. `4t:-i—'�­t:'��='.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 /> 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,1 certify that the contents of this consignment conform��the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in OtPR 262.27(a)(if I am a large quanUty generator)or(b)(if I am a small quantity generator)is true. <br /> Gertor's/Offeror's PrintedrTyped Name Signature Month Day Year <br /> _J 16,lnternatidhal Shipments <br /> 1— 11 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> 91 Transporter signature(for exports only): Date leaving U.S.: <br /> O� 17.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> 0 Transpoder 1 Printed/Typepi Name Signature Month <br /> Day Year <br /> Z Transporter 2 Printedrryped Name <br /> Signature Month Day Year <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity 0 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> In 18c. I _ T <br /> LLj Signature of Alternate Facility(or Generator) nth 7Day Year <br /> tR <br /> Z <br /> 0 <br /> as 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 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 />