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Please print or type.(Form designed for use on elle(12-pitch)typewriter.) Form Approved.OMB No.2050-003! <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page,1 of 3:Emergency Response Phone 4:Mahtfest Ira Numh r <br /> WASTE MANIFEST C. 000350717 1 05.823-8772 <br /> 5.Generalor's Name and Mailing Address Generator's sits Address(d different than mailing address) <br /> L tS9fleRSAL SVC RMYCLM Atn Wfllam Wf aorlea <br /> 3200 i,El Dorado St. <br /> S10Ck10,CA <br /> Generato's('hone: <br /> 5; Mans er 1 Company ame U.S.EPA AID Number <br /> L#rtion Pwft Linn CO <br /> t=170910- <br /> 7.Transporter <br /> 7 iu7.Transporter2 Company Name U.S.EPAID Number <br /> 8,Designated Fadity Name and Site Address U,S.EPA ID Number <br /> ECDC Envil -ifF '#32Q+ <br /> 1111 West 123 <br /> Facility's Phone. <br /> 1 Easi Cmim,bT M520 USA <br /> 93. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Un':t 13.Waste Codes <br /> HM and Pacldng Group(it any)) No, Type.. Quantity 4ilivo! <br /> QQ iI%V I-RU A {"fit OW WASTE, 04m-DOT ) 001 T <br /> LL' <br /> W 2• <br /> .r < <br /> 4. - <br /> 14,Special Handling instructions and Additional Information <br /> I-ffiUVeRVLLSERkCYCLMGPROMICT No, <br /> 15. GENERATOR'SIOFFEROR'S.CERTtFtCATION: i hereby deefara that the contents of this consiynmentara .and accurately described above by the proper shipping name,and are class fief,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable infcmadonal aril national governmental regulations.If export shipment and I am the Primary <br /> Exporter,tcertfy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> Ire*that the waste minimization statement identified In 40 CFR26227(s)IN I am a large quantity generator)or(b)(If)am a small quantity generator)is true. <br /> Ge s PdnWyped Name Month Day Year <br /> i <br /> U# I � 17 v7 <br /> 16.Intema6ona(Shipments F1 import to U.S. ❑Expert from U'S' Part of entryle)k <br /> Trans r `nature for ex { ',.. Dale lea' U.S.: <br /> W 17.TIa.... "`rental ,Qj• ,?•.: .. <br /> Transporter 1 FrtntedlTyped Name 1515nawre -7 Month Ely ear <br /> CL i J . lA <br /> d Transporter 2 PrintedlTyped Name ignature on ay ear <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity, ❑Type El Residue Pa !Rejection <br /> Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> 4 <br /> <1 Fadi'ys Phone; <br /> ti18c:Signature ofAl emale Facility(or Generator} Mornih Day„-- Year. <br /> 19.Hazardous Wiasta Report Management Method Codes(Ie_codes for he aidous waste treatment,disposal,and recycling systems) <br /> 2, 3. <br /> 20.Designated Fadtty Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item!Be <br />` rim Name Month Day Year <br /> 1,77 1 <br /> EPA Form 8700-22(Rev.3-05) Previous edifions are obsolete. L, DESIGNATED FACILITY TO GENERATOR <br /> l: <br /> j' , <br />