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0 <br />Please print or tvpe. (Form designed for use on elite (12 -pitch) tvpeMter.) <br />0 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />213 J J <br />WASTE MANIFEST C: i_i)r 81.9 tati i tA'`i <br />t <br />(400-,'146- 7440 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />908Im'`VAK; tRIJCNW.-� <br />17333 C t1MC,C7NE'A RO <br />dTECAt, (A 95:1:311 <br />Generators Phone: ?09-:734.3-X17 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />SiiCsV H. -VARUS S(A-U ft(3hiS CAOI.41064 64 Q7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. P U.S. EPA ID Number <br />UX <br />1113 'd'ttTE f iJ+.-'he t1 (:.d1?�1�tl.lfR( 11FV' <br />RANCHO COPO-DVA, (A 95?41 <br />Facility's Phone: <br />9a, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Numbor, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WL/VoI. <br />1. :. ry691(y s-/•. U,5 u,i I 1./, <br />2 <br />PA <br />311 <br />P <br />223 <br />:35: <br />(.c <br />iL <br />W <br />2. <br />3. <br />4. <br />14. Handling dling Instructions and Additional Information <br />VR H E 0 <br />F%1.A1�-PR(MEClivL Q,c.:>1' #W <br />EEERG #IJ1 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this oornsignment are fully and accurately described above by the proper shipping name, and are dasMW, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and i am the Primary <br />Exporter, I certify that the contents of this consignment conform to the of the attached EPAAcknowledgment of Consent <br />I certify that Bre waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (B i am a squall quantity generator) is true. <br />Printed/Typed Name r Monifl Day Year <br />W7Otferces <br />�M A S -A1-- <br />I�- <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />= <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />o, <br />T 1 PrintedlTyped Name e , e Signature. - d Monte Day Year <br />QT <br />r 2 Pdnted/Typed Name Signa Month Day Year <br />fY <br />1- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. A temate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />U <br />Facility. Phone: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q® <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. 2. 3. Notice: New federal form. State of <br />California requires generator to photocopy <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and mail to DTSC within 30 days: <br />Printedffyped Name Signature P.O. Box 400, Sacramento, CA 95812-0400 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />