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• <br />Please print or type. iForm designed for use on el9e 02 -pitch► typewriter.) <br />C7 <br />Foran Approved. OMB No. 205"039 <br />EPA Fort 8700-22 (Rev. 345) Previous edibW arffbsEtete.. GfQATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator D Number <br />CAL00( 22421 <br />2 Pape 1 of <br />2 <br />3. Emergency Response Pune <br />1-08-7W7225 <br />4. Mo ttest Trac kung Maribor <br />FLE <br />WASTE MANIFEST <br />5. Generaw's Name am Generalos Site Adrkess fif diiforerd then mathg address) <br />011 :� �iC. <br />Y <br />Stad*01 CA <br />Generators Prime: 91 62000604 <br />U.S. EPA la Nuuedry <br />` <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Des' naiad Faady Name and Site Ad�dre`sss U.S. EPA ID Number <br />us Nrwmb �:ic�%��} <br />PO Boot + 31.7.;; wean 8 <br />eye y, w <br />Fadi 's Phone: <br />ga. 9b. U.S. DOT Desedpion fndWhg Proper Shipping Nene, Hazard Class, ID Number. <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waaler Codes <br />No. <br />Type <br />HM and Palling Group It &n9) <br />QuantAy <br />WINd. <br />X 1. <br />weIhylpropAWbMJde66=*�3.PGVl <br />Ga>" <br />P <br />DOM <br />331 <br />— —t <br />-,GF <br />14. Special Harx" lnskuefions and Additionat krhrrnatim <br />f �1fh1tW leis" Docurltertt 1307 <br />iwsm is SoDRO_..�- �'-f LY9 i2O*1 f M S <br />2=1 <br />0701 <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conleits of this consipment are fully and accurately described above by to proper shipping name, and are dasdad, packaged. <br />marked and NbeleuUpacazded, and are h all respects in proper condition for transport acoordang to applicableinternational and national governmental regtdallons. If export shipment and I am the Prrney <br />Exporter, I certify that to kxnbards of this consignment conform to the larks of the attached EPAAcknowledgment of Consent. <br />I eerily that the waste minimization statement Identified in 40 CFR T I am a large qu w* generator) or (b) ' I am a small quantity gewator) is true. <br />ierator's 's ped Name <br />a ear <br />IrAwnationsfShiprilents El Im fa U.S. ❑ Export S. Pot of entrylext: — <br />Transporter signature icor only): Date leaft U.S.:_-- <br />17. TransporterAcknow dWrient of Rao* of Materials AS <br />Tra : t <br />Mvypad Nanhe. hgnatur ay , Year <br />j'j( •— <br />h <br />►� Zi <br />Transporter 2 Prod yped Name I signature yraw <br />18. Discrepancy <br />��--77 <br />18a. Discrepancy Indicaton Space 1:1 Quarntity ❑ Type L.1 Residue Parliai Rejection ❑ Full Rejection <br />i tt'�G CQ Cott eS dull t p � PkKi 110* �4Vk(,er f CV1GM: a j <br />Manifest Reference Plumber: <br />18b, A ternatu eciily (or Generator) U.S. EPA ID Number <br />I'acAilYs P1:ore: <br />W <br />180. lurecfAternatsFacNty(orGseraicr) Mkxdh Day Year <br />a <br />Iz <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste keaknent, disposal, and recycling systems) <br />0 <br />1, <br />2. <br />3 <br />4. <br />20. DeNgnated Facility qww or Operator: Certification of receipt of hazardous materials covered by the merdfest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />Citi <br />EPA Fort 8700-22 (Rev. 345) Previous edibW arffbsEtete.. GfQATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />