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Please print or4' Form Approved.OMB No.2050.0039 <br /> type,(Form designed for use on elite(12-pitch)typewriter,) w-�.. w <br /> UNIFORM HAZARDOUS 1.G ewetIorL1D�ium er 79 7 2.Page 1 of f m�er?oRnsa Phone 4.ManHast Tracking Number <br /> WASTE MANIFEST kkff <br /> 2X8712 969 23-06 FLE <br /> 5.Generator's Name and Mailing Adq �� A� 1 REG t!I f(; tkfA UuliltS#ft Gionaratot's Site Address(if different than mailing address) <br /> L 4,Sto4vjn,CA 95M <br /> �0: Generator's Phone: J <br /> ranspoRer 1 Company Name_ US,EPA 10 Number <br /> .h <br /> 7.Transporter 2 Company Name U.S.EPAID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA ID Number <br /> COC F=QNfftS1U ientBI UTC0'M112121u <br /> 1.111 WestHo 1:n <br /> FW,44A-4.461 East('�-uboft,€ T zs4520 USA, <br /> FaaGtys Phone: <br /> ga 0b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it,Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WIIYoI. <br /> W <br /> 4.' <br /> 14,Specht Handihmg instructions and Additional,,Information <br /> Pd ►ResidueMIX . <br /> W4041 16846 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hareby dedare that the contents of this consignment are fully and accurately described above by @me proper shipping name,and are ctassilled,packaged, <br /> marked and labeled/placarded,and are in all respects in proper rmndition for transport according to applicable international and national govemmental regulations.If export shipment and I em ft Primary <br /> Exporter,i certify that the contents of this wnsi nment conform to the terms of the attached EPAAcknowfedgment of Consent. <br /> I certify that the vresta minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b I am a small quantity generator)is true. <br /> enera eror's Printsoffyped Name igna Ron= ay ear <br /> 7 ', <br /> _r 16,International Shipments r <br /> ❑Impart to U.S. l J Export from U.S. Port of entry/exit <br /> Trans iter s'nature for ex its only): Date leaving US <br /> 17 transporEw �• 4: •; A i k, <, <br /> Transporter i PdntedlTyped Name _n re ,, 7 :. i ,-n y_ ear <br /> ; s f rs0 ' <br /> Transpo ter 2 Pr ntedfTyped Name MonffF ay Year <br /> F <br /> 16.Discrepancy <br /> 16a.Discrepancy Indication Space J Quantity EIType t Resid. ej ) <br /> ❑Partial R action ❑Full Re eciton <br /> MaLmW Reiarence Number. <br /> t6b.Altamate Faclfty(or Generator) U.S.EPA ID Number <br /> v <br /> d... <br /> w, t.6c;,5ign,?pire,ofAitemataFec�ly{or. ,.. hx� ;; 4 .,.` `; <, EMnth Day:- Year'. <br /> :iq.Hazarcbvs Waste Report Mona <br /> gement Matw Codes(t a,codes for hazardous este Uaatrnent dssposai;and <br /> � <br /> 1 �w 2: 3 4. <br /> e11 <br /> 20.Designated Facility Owner or Operator:Certification of reteipt of hazardous materials covered by the manifest except as noted in Item I6a <br /> Pnn ypedName Signature Month Day Year <br /> P <br /> EPA Form 6700-22(Rev.3.05) Previous editions are obsolete. zz DESjGNTEtI'FAClI{TY TO GENERATOR <br />