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Please grin j type.(Form designed for use.on-elite(12.pifch)typewriter.) ;. I`Om Approved,OMB No:.2050.0039 <br /> +f U 1.Generator ID Number 2.Page 1 of 3.Emergency Retponse Phone 4,Manifest Tracking Number <br /> AORM HAZARDOUS.SCEMNtFES7CA t: 5. t2C$) t�' , p s s ; <br /> : ¢. JJ <br /> 5,Ger)eratofs Name and Mailing Address GaneratoPS Site Address(if different than malting.address) <br /> P[OK R PULL 080 <br /> 3927 OLARK,OR <br /> OA 952-5, <br /> Generator <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RLbOi!ENV3 NK1ERTAL-sZR1ft0E gra "_ 'r <br /> 7,Transporter 2 Company Name US.EPA 10 Number <br /> 8•Designated Facility Name and Sle Address U.S.EPA ID Number <br /> AMW ENVIROEVMF TAL SiaRVlGF CERE a <br /> J-920&ttlORGAN RD. <br /> CA 'AL 00398680 <br /> Faalriy's phone::' . 1�7rltit'ti��-t_ ¢�, � .• ...,:.. .:.-. <br /> ga• `01b.U.S,DOT,Description(mcludingProper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> 13.-Waste Codes <br /> HM :a9nd.PeokkingrGrouppAOf any)). �/[, Y e S t qY4 1 8 6 ! {yS k[ No. Type Quantity Wt.Nol.,, <br /> .�t i4.`i+l^Y•'SifYti•3'S i31�St�.dX6'ei�.+O[,i.."Y we F,'C,�1Oulp�f+1sm Oil-/�l�Fdh l.T OIL) <br /> T T " <br /> .•". <br /> Uj <br /> LU <br /> i <br /> a, <br /> ( Asbr �•,rr.,,�arvu,us-C,etes <br /> !�,;urupriate.permits to . <br /> recr.i• a.; ;•and haseivei8.yoiirwaste <br /> 4 <br /> �V <br /> 14.Speclal Hantllinganslttictioti'spfiBAddiiion-a information <br /> tna'iLOi4iIINAL: Y'Af"PRt7FxIdAlt it <br /> q'too.-424-5' TWO)i <br /> 15. GENERAFM R?S 01�"Ft`S G t�iF1GkC Ofil"""I lieYeli d&clans that the contents of this cdnsignmentara.fuliy and accurately described above by the proper shippingriame;and are classified,packaged, <br /> marKed ai d`.iz ie)edT�taca','ided;;ptular&!Hall gas is in Pi6per eondiUonfor'transport according to applicable f6t6mationai and national governmental regulations.If export shipment sod lam the Primary <br /> Exporter,l cenbfythatthe corltsrttsrof ffiie consignment conform to tti0 terms of the attached EPAAcknowledgmeM of Consent. <br /> I Ceihty'that tYi""@yrasce glfnJrofZagon staYementTd6nti ed In 40 CFkk'27(a)(if t am a large quantitygenerator)or(b)(if I am a small quantity generator)fs"true. <br /> Generator'sfOffetor's PeOWTyped Name Signature Month Day Year <br /> 16.Intemat inal.Shipment§ El from U.S. Port of ant !exit <br /> ^❑Importdo.U.S." ry <br /> — .Trensp6ntesfgiatbYe,(f¢r.:ex¢ort§.only).";„ ..-. , , Date leaving U.S,: <br /> 17.TragsporterAclmowied•gmW,'6fRbceiptofMafaffal5 f <br /> Transporter 1 Printedf.Typed Name Si niotune ii. Month Day. Year <br /> i� gYlf 71 <br /> Transporter Printedfryped Name Signature};elMonth Day' Year <br /> t� <br /> 18.Discrepancy. <br /> 18a.Discrepancy Indication Space U Quanti' fr--�ti ❑partial Re ❑Full Re <br /> ty l l hype ❑Residue Jection ject on <br /> Manifest Reference Number: . <br /> 18b,Alternate Facility(or Generator) . U.S.EPA iD Number <br /> Facility Phone: <br /> 18c,Signature of Alternate Facility(or Generator) Month Day Year <br /> 19,Haiardous Waste Roport Management Method Codes(I.e.,.oddas for hazardous waste treatment,d;posit,and recydipg systems) p <br /> 20•Designated Facility Owner or Operdv"f C ficatlon of receipt of hazardous materials.oovsred by the manifest except as noted In item 18e <br /> PrintedCTgped ams c" p. Signature /;� g onih Day Year <br /> �n `5 4, .'aky :fes –Y ff� Vii:. aFr <br /> EPA Form 8700.22{Rev.3-05) Previous editlbns are obsolete. S DESIGNATED ED FACIL9`TI`Y TO G8NERATOR <br />