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t <br /> Form Approved.OMB No.2050-0039 <br /> (Form designed for use on elite(12 pitch)typewrites) 4.Manifest Tracking Number <br /> HAZARDOUS 1.Generator IDue [)�i087, � fi --T2,Pale 1 of 3.Emergnte00 <br /> �is �se� n <br /> CE MANIFEST 1 JJ K <br /> er s. a an al i q d r s� Generator's Site Address(if different than mailing address) <br /> s[�z ,;N� t. e arlti�t:oa003 East kti ersctY:Y fid»t <br /> P.O.�gox 81 �3 S5'.cvxy tCy+.t,CA.�;-71.2 <br /> 2�09-~�-E-4"A <br /> Generators Phone: U.S.EPA ID Number <br /> 6.T, nspp�er Cpm anyy N e .',:•:'UE1 s ?' f. <br /> �fs!'liE,6li <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.tDgigtr Facility Name and Site Address f.:P <br /> P1)7-493 Gfill A <br /> Facility s Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM <br /> and Packing Group(if any)) No. Type Quantity WtNol. <br /> f <br /> 1. 1`401a t•C:1A 4liit?i'doili was O.itattct)(1t15,G'd Oil) sgi rtn �2. I <br /> W <br /> ��� I:�o-n has the anwt Itis!-€I�.� " <br /> I <br /> 3. 1 <br /> tl°c.°J�lae 4.:a�-,�. ice.' �F elm 's,V�fl���:�d 3ui 4„•d'n� (a4a��I�'"- ,v:.G.... i <br /> i <br /> .....gym............._,.-.....�...........-.... ;: <br /> 14.Special Handling Instructions and Additional Information <br /> if`�z5^�' �'�"$:a;`i P{i���?.R?.f_t��..;, i;s_+f't'�3t6.'��e''9±34 ttr �_`!'".`fdt�].t•..'� �i'iii YSJ: <br /> 15. GENERATOR'SIOFFEROR'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, <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 N <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b�(ff I am a sma quantity generator)is true. Month Day Year <br /> Generatoesl0fferor's<ennted/T(y'ped Name Signature <br /> .j 16.Intemational Shipments ❑Import to U.S. ❑Export from U.S. 6 Port of entrylexit <br /> F- Date leaving U.S.: <br /> z Transporter signature(for exports only): <br /> W 17.TransporterAcknowledgment of Receipt of Materials Month Day Year <br /> I Trans er 1 Printedffyped Name ^�,,`� Signatur <br /> O dJ � 8 l `�/.•L�'y� c 3fc.c•G2✓c1 *- 5,� / <br /> IL f tt�r� " + 1 t --- Month Day Year <br /> W <br /> Transporter 2 Printedrryped Name Signaytuf <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Mternate Facility(or Generator) <br /> J <br /> v <br /> LL. Facility's Phone: Month Day Year <br /> 0 18c.Signature of Altemate Facility(or Generator) <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> Uj 2. <br /> 3. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be Month Year t Signature Day Yar <br /> ed a / a Ye r <br /> Printedrr Na „ <br /> � [ "f <br /> e t I <br /> � ri.�;,_ J4 rte. 1 .n'ar! �_:!".r'�� r ,�,�_ .aA !� jLi <br /> EPA Form 8700-22(Rev.3.05) Previou editions ate obsolete. ',+`DESIGNATED FACILITY TO GENERATOR <br />