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Please print or type.(Form designed for use on elite(1 2-pitch)typovinter.) Form _ <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 14,Manifest Tracking Number <br /> i <br /> PO BOX 1210 102 HANSEN DR <br /> LODI CA 96241 LODI CA 95240 <br /> EPA I <br /> 1.qT8Vt&b&jjN&IeA11ia,, U.S.EPA ID Nurnher <br /> HWY 95 11 MI S OF CY 16 ACRES <br /> BEATTY NV 89003 <br /> 9a. 90.U.S.DOT Description onclucing Proper Shipp;ng Narne,Hazard Cass,ID Numbor, cclitainers I I I Total 12,Unit <br /> HIM and Packing Group(if any)) No. Type Quantity WI.Nol, 13.ftiiste Codes <br /> I.NON-RCRA HAZARDOOS WASTE,LIQUIDS ER BASED 343 <br /> 14,Special Handling Instructions and Additional Information I)Ub U101 31570-8829 W-51er Saseaftnf Ritsate RG#171 <br /> IIANDLE'ItS TO BE I W011XAINRI)'ALNI)11SE PPE.—ER Colunict/1205907 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deflare trial the contents of this consignment are fully and aLcufately described above by the proper shipping narne,am are classified.packaqiul <br /> marked and Ithelodiplacarded,and are In all respects ir proper cond,tion fur transport according to applicable internationaland national govarrunentai regulauins.if export 6luorrient and I am the Primary <br /> Exporter,I certify trial t1he contents of this cons'grununt conform to(he terms of the attached EPA Acl�riowledqmont of Consent. <br /> I certify that the waste rnittirnization statement identified in 40 CFR 262.27(a)(if I fun a large quantity qenoiawr�kr(b)(0 ain��Tiall quamily generator)is true. <br /> Gen offetur's P I ryXP N Monuh Day Year <br /> -j 16.International Shipments <br /> Transporter slUiaitufe(for expuds unly): Data leaving U'S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU j <br /> 1�— Transporter I PrinioNTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity Type Residue Panial Rejection Full Rejection <br /> ,10anifesL Reference Number: <br /> 18b,Alternate Facility(or Generator) U,S,EPA ID Number <br /> Facility's Phone: <br /> uj 18c.SignatureofAlternate Facility(or Generator) Month Day Year <br /> CD <br /> Fn 19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> HA <br /> W �21 -T- -T <br /> 1, Ro- /N <br /> 5, ous materials covered by the nuiniffisi except a <br /> Prinbulffypeul Nami,, VAr L fA Ih Y ar <br /> L1111.......... i�-I G I i`i� , <br /> EPA Form 8700-22(Rev.3-o5) i5rovious editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> } <br /> / <br /> / <br /> � <br />