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Please print or type.(Form designed for use on eche(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTraddng Number _ <br /> WASTE MANIFEST I i.. : —; ' < f V'A' 4=t i. 2091 100774769 7 JJ K <br /> 5.Generatofs Name and Mailing Address Generates Site Address(idifferentthan mailing address) <br /> Generator's Phone:- - ° CA F1''' ;gib'i '-1-• 22- <br /> 6.Transporter 1 Company Nara U.S.EPA ID Number <br /> 7-Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> .. .. _ <br /> Facility'sPtt"E"`; ! ' l;,yr 5.ti CRF_? <br /> ga. 9b.U.S.DOT Descriptor(including Proms Shipping Nance.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type QuanBty WLNd. <br /> 1. <br /> 2 .2. <br /> tl1 <br /> 0 �.._.. .._.....-._ _._ <br /> 3. <br /> 4. <br /> 14:Special Handling Instrurs and Additional information <br /> Ufas6z4:-fMA. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are filly and accurately described above by the proper shipping name,and are dassitiad,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condlition for transport according to appiksble international and national governmental regulations.N export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgmerd 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 small quantity generator)is he. <br /> Generetoest0flerofs Printed'Typed Name Signature "x Month Day Year <br /> ,_.• �.. <br /> 16.International Shipme In,por to U.S. ❑Export from U.S. Part of enWexit <br /> 2 <br /> Transporter signature(for exlibrtsony): Date leaving U.S.: <br /> 17.Transporter mint ofReceiptof Materials <br /> TranspMef 1 Printedfryped Name / ( Signature r Month Day Year <br /> ai,. 1 <br /> Z Transporter 2 Pdntenl ted Name Sig Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space F] Quantity []Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manliest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a ; <br /> U <br /> Facifily's Piton: 4 <br /> Jul i8ds Signature ofAftematoFacility(or Generator) Month Day Year <br /> 2 i <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste beabnent,disposal,and recycling systems) <br /> Uj <br /> 1' <br /> 2. <br /> 3. 4• 1 <br /> 20.Designated Facility Owner or Operator.Carefcation of receipt of hazardous materials cowered by the manifest except as rdde1 In Item 188 <br /> PrintgdfTyped Na Signature Month Day }Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) j <br /> n <br /> E <br /> i <br />