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Please pant or type.(Farm designed for use on elite(12-pitch)typewriter_) Form Approved.OMB No.2050-0039 1.Generator ID Number 2.Page f of 3.Emergency Response Phone :Ja5ffest Tracking Num erUNt ASTE HAZARf}f}t!S �WASTE FAANEEST G A L7 O 2 9 4 b U 7 >d l 3i1,. 2 JJ 5.Gen Adt(r Generators Site Address(if different than mailing address) 'g td I M €� Generatar's Phone: 6,Transporter 1 Company Name U.S.EPA ID Number 7.Transpurtar 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number WORLD OR RECV;LR46A Ota;ALAMEDA STREET j Facillty'sPhone: f`aI1t.r'b71 71r;{; 9e, 91h.U-S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes RM and Packing Group(if any)) No. Type Quantify WtNol. 1. floN- PA FL1+a t`i OOL1S '-f Li40Ld iliA.OGENA ED OIL OVER `E 741 LU 2. i i 3. 4. I f 14.Special Handling Instructions and Additional Information IFkAFRGV'a$Ct7Fd7,AC : M4EWDE- I-WO-4:4- 360 WOES TERMIP-14 CFRES WPOO 9BI 1.71 PROFILE 931 . 71G19 At f°IONF 401_EFTA CODES'MI ONE �A 'FVOPFF!A T PE [SNAL PROTECTIVE EQUIP PIT E 15. GENERATORVOFFEROR'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, marked and Iabeledfplocorded,and are in all respects in proper condition for transport accorcling to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,t certify that the contents of this consignment conform to the Terms of the allached EPAAcknowledgment of Consent. I certify that the waste minimizalion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(i€I am a small quantity generator)is true. Gsneratorsl0fferor's PdntedlTyped Name Signature Month Day_ Year i.a 116.btemadonal Shipments il- ❑Import to U.S. ❑Export from U.S. Pod of enlrylexit; K Transporter signature(for exports only): Date leaving U.S.: Ed17.Transporter Acknowledgment of Receipt of Materials tE Transporter 1 P nted{Typed Nama Signature Month Day Year Transporter 2 PrintedlTyped Name Signature Month Day Year f- 18.Discrepancy 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA TO Number C.3 U- Facility's Phone: lm 16a Signature ofAltemale Fac lily(or Generator) Month Day Year d 19.Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and recycling systems) UJ t. 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a PrintodiTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3.05) Previous edilions are obsolete. GENERATOR'S INITIAL COPY