Laserfiche WebLink
Please.print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST, <br /> {::,I_>�: t?�i° if:rL j - r� rU 00 2 8 3 2 0� s Ks <br /> 5.Generator's Name and Mai'mg Address Generator's Site Address(d ditferent than mailing address) <br /> Generator's Phone: <br /> 6.Trmporfx 1 Co(mM Name U.S.EPA ID Number r7, <br /> ;rfs s:,:�'f`F'.i._.. ,y -"ST }yl_>e <br /> 7.Transporter 2 Company',Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address y_ , r: �. r�;; -!=PAID Number <br /> 6000 88TH STREET <br /> Ojai:t7P. NT 111 <br /> Facility's Phone: <br /> ga 91b.U.S.DOT Description('mduding Proper Shipping Name,°Hazard CIBes,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity Wtivol. <br /> 1. <br /> :,:; :.I.1: t C. X.;�tt43rt1 t}1t.� L.1!�.1 Y 47S, :rt", <br /> iss'1?�z;, { i,..':i"� 1?�.L4 • t7}7Ir} 11JRI_F} .} p <br /> Z 2. <br /> W <br /> (D <br /> l <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information. <br /> ��= P'�: f..r�iF�j4f��'r•:(_.� �j,:.�y-g7.,.�E�I•�„'`•'1Fs wi 1 r Aj ,.. �';�jS•;'� a •iFY Z 7 <br /> f:' ,} itiw 2'4 iii 'iti s Ri i ?f°C9Ir'F:11 'Al i0i:44 i1 ' '' f, . >+ s„ ! "t d <br /> 15. GENERATOWSIOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ard 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 EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 26227(a)(d 1 am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> GeneratorsfOfferor's Printed/typed Name Signature Month Day Year <br /> /Q !/ <br /> .j 16.International Shipments <br /> F ❑Import to U.S. ❑Export fram U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transported PrintediTypedName Signature Month, Day Year <br /> Q Transporter 2Printed/T Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑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 /> Lj- Facilites Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F- <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ G 1 }Siti.t 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 /> nntediTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous aditions are obsolete. GENERATOR'S INITIAL COPY <br />