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Plonto nrinf nr tane [Fran desinnM fnr use nn ARA. (12-nifc,._-newri[er.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. �� DESIGNATED FACILITY TO GENERATOR <br />k 3� la zf ed cc.e✓4?h t <br />UNIFORM HAZARDOUS <br />UNIFORM <br />1. Generator ID Number <br />2. Page 1 of <br />l <br />3. Emergency Response Phone <br />F-Tracking Number <br />000894540 F L E <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address Generator's Site Address(if di Brent man mailing address) <br />San 1uagqU),� Cu Solid U-4str �lU)Sia1 A tN 11)rnbra. Arldr('�S <br />Tf-U. ►30X lee Sia n Joaquin 00. Nousehole) Was <br />j� <br />Generators Phone: '(7f C� )0A1 yea Bow, E. <br />6. Trans po er 1 Company Name U.S. EPA ID Number 5. <br />L 7) C'%1q <br />7. Transporter Company Name U.S. EPA ID Number <br />8. Designated <br />Facility Name and Site Address _ U.S. EPA ID Number <br />W -C. Cull • IANC <br />'JDIPTI <br />Hun}wocO AUC . <br />Facility's <br />.c t <br />Phone: (- <br />ga <br />9b. U.S. DOT Descrip on (including Proper Shipping Name, Hazard Class, 0 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (it any)) <br />Quantity <br />Wt/Vol. <br />1 RQ �ckjchlortriajerl <br />c240 <br />una315)-06g <br />Z <br />W <br />2, <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />pe <br />y q .. <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, 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 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (if I am a small quantity, generator) is true. <br />Generator's Offeror's Prinledrryped Name bignmuna , Month Day Year <br />4ufat/ <br />-.1 <br />T-- <br />16. International Shipments <br />Import to U.S. ❑ Export from U.S. Port of entrylexit: <br />- <br />Transporter signature for expons only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />C <br />Transporter 1 PrintedRyped Name Signature .%'1 Month Day Year <br />I <br />y <br />e 0, 't rtC.K N' %� �' 110pt <br />Q <br />Transporter 2 Priv ed yl>ed Name I Signature Month Day Year <br />r <br />18. Discrepancy <br />1 Ba. Discrepancy Indication Space ❑ Quantity Type El j <br />❑ yp El Partial Rejection Full Re ection <br />p <br />L. (F9-- 1'' 1 f 5 a g5 <br />Manifest Reference Number: <br />18b, Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />f <br />a <br />at <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility(or Generator) Month Day Year <br />Q <br />Z <br />y19. <br />Hazardous Wdste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner Qr Operator: Certification of reraipt of hazardous materials covered by the manif st cept as noted in Item fila <br />Pnnted/T ed Name Sig r Month Day Yp�L`7 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. �� DESIGNATED FACILITY TO GENERATOR <br />k 3� la zf ed cc.e✓4?h t <br />