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Please print or type.(Form des net!for use on elite(12-0ch)"veer.) Form Approved OMB No,20SM39 <br /> UNIFORM HAZAROOUS 1,GumraV 10 Number 2.Page 1 of 3.En"*rry Response Phone4. anifaa!Tnekan dumber <br /> WASTE MANIFEST s�At_It 3 5717 7 416,92 (1772 � # <br /> 38696 FLE <br /> 5.Generators Name and Matting Address Genefeta's a Address(t!ditent uaan a"address) <br /> 1.1 41/1EHM 13V0 RnG11 r,k£.(w 144"i't Tt Nei t"a <br /> 9tookl6it,CA <br /> Genarato+'s Phew: at'rt�° 44�` 3 <br /> ranspo-ner 1 Ca6pany Name U.S.EPA l0 Ntm *r <br /> klnif'S,r ppTd,,B}1tt F'i 'a d ,t; <br /> 7.Transporter 2 Company Nam* U.S.EPAIO Number <br /> B.0asQratad acr,ty Nam*and 6,10 Addrass U.S.EPA f0 Number <br /> t111 e'ST MjhvMi I Ti�II €I1 n?tlt <br /> ga. <br /> 0.US,DOT 0ascripbon(6,6WM Prior Sh;.W'rg Name,Hazatd Class,IO Number, 1o,Cordat+tots 11.Total 12.Unii 13 waste Codas <br /> HM and Pacdng6=9(darry)) No. Type Q.way %%Not. <br /> I' 1 <br /> t,iµat .AZARDO a VA '�, ( 't rrD0'f riios11 L d', C 1 NG [( 1 <br /> :K 2. <br /> 3. <br /> td.Spasaat HandFnq lns'vvdt ons and Mortal Intormation <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION:I neraby dodam Out fit*cralants of or s asosigrenant am"and aoaaatety desaabed abtwo by ft proper sNppEng name,and are cb ss1w,poftw, <br /> marked and tatlNed p.rcardad,and aro in 0 respects in propar condition for transport a000rdirV to epplicabla Intamallwal and national pav mmantal reptdallons.N export$howl and am ft Ptxnoryr <br /> Expo ter,I oert4 Haat dee cmtants of this wrai nment coni m 0 ft terms of flee atis&Ad EPAAdmaaledgrnent of Consent <br /> I c,!6ty Ihai dee waste m nuzation statement IdenVW In 40 CPR 262.27(a)(t t am s larpo quviW ganorata)or(b)(N I am a"I quaniky gemma r)is into. <br /> anard .a a ftntedrTypad Name #jna re edf <br /> tdi.Inlamatkxa 5t"pmens <br /> �. ❑Import to U.S. Export trlkm U.S. Pat of er>xytsxie <br /> Trans rs nature fora s Dateleav U.S.: <br /> 17,Transportai A6Nm%dgrwt of Receipt of Mateda's <br /> ransportar I PIM yped Name ear <br /> VtfnA(AA 1J�o 130 119 <br /> Transpod.^r2P edllypadName gnat" y cat <br /> 18.0scapanry _ <br /> lua 0;wepancy lydzatzata Space C zn y ❑Two ❑R.W. ❑Partiai Rej om Fug Re}ectial <br /> Manifest Raferenns Number; <br /> leb,A1ti Emit(F.Ity(oe 000a10() U.S.EPA 10 Nembet <br /> J <br /> t3 <br /> Q <br /> 16c.Sgnatore of Metnate Fact+ty(a Ger xainr! �f th Day Yost <br /> d <br /> 19.Hazardws Waste Re on Mans awn Method Codas(r e.,oodm for hazardous waste t oatin¢t,disposal,and recycling systems) <br /> � <br /> t. � P 2. 3. 4. <br /> 20,Dnsjnatad Fae ty OAM or Oparatot:Cen:Am ion of receipt o(huatdars materials covered by the marddest except as now in item t6a <br /> Fnntadrtypod Nemo k�nature d1 y ear <br /> Vol� �-� <br /> EPA Form 6700.22(Rev,3.05) Pre'•ious editions are obsolete. DESIGNATED FACILITY TO GENERATOR ST TE(IF REQUIRED) <br />