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• <br />Dr. e not n. hmn /Frim Ane .moil fnr ucra .x� nLre r19�ufchl tuflPWrllor 1 <br />0 0\\\10 <br />Form ADDroved OMB No 2050-0039 <br />EPA FM 8700-22 (Rev 3-05) Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (IF MQUIKtU) <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />CALOt»21 <br />2 Page t of <br />3 Emergency Response Phone <br />11-888-785-72250 <br />14 Mandest Tracking Number <br />08827008 FLE <br />WASTE MANIFEST <br />5 GeneraWs Name and Maikng Address Genaralors Site Address (d different than mailing address) AFFIX TO RIGHT SIDE <br />Si"WAY OF ALL HAZARDOUS <br />BILLS AT LINE <br />S CA 9M SO <br />SO TAB WILL STICK OUT <br />Generators Phone 9184 <br />6 Transporter 1 Company Name US EPA ID Number rla2T> e r c c uaa r wo-liar saes <br />TMM4w t inc. (sV) c,�Ra�a7o�a0 <br />7 Transporter Name / USE DNumber _ 0000 f73> <br />8 Designated Fadty Name and Ste Address S EPA ID Number <br />wMeco chellwCal iriotrim bw X1057870 <br />1007 VWcan Road Haskeg <br />'BAR 72015 <br />FacdiVs Phone 501 <br />ga <br />9b U S DOT DescnpUDn (alluding Proper Shipping Name, Hazard Cim, ID Number, <br />10 Containers <br />11 Total <br />13 Waste Codes <br />No <br />Type <br />HM <br />and Packing Gmap (dany)) <br />Quentty <br />X <br />i a S, tua r4 (Daof <br />lF <br />11AIN61 <br />eml <br />181 <br />� <br />z <br />2 <br />W <br />3 <br />4 <br />14 Speaal Handling instructions and Additional Inkimmbon <br />Pm*t MAW 7W47 0=90ent # OBIE34 <br />1)ERM"28; I M13 -MM Sa:X b#h)- <br />t JI <br />15 GENERATORWFFEROWS CERTIFICATION I hereby Aare that the contents of this consignment are hilly and accLsately described above by Um proper stepping came, and are classified, packaged, <br />marked and a abeledlpkacarded, and are in all respects in proper caidtwn for transport aceaduV to applicable international and natal govemmertal regulations It export shipment and I am the Primary <br />Exporter, I ce* that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br />that the waste mcen¢atan statement identified n 4'0 CFR 262 27(a) (d I am a targe quantity generator) a (b) (d 1 am a smn quantddyy7generator) is true <br />Pin }ped N OAJ ��GiiLW- Dap-' Q 1V ole#444e OMonth � <br />lam s S Al i G r <br />116 livitarribb.WShipment, Import to U S Q Export from U S Port of entry/eim <br />Z <br />Transporter signatuire for exports ori Date leaving U S <br />17 TraiispoftAAclarawiedgment of Receipt of Matenals <br />ran 1 yped Meme ignature Month Day Year <br />O <br />Ar Alla <br />Tra rter 2 Pmtedfi Name r gnaiuie ear <br />rQ <br />18 ncy <br />18a Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Pads" Relecti. ❑ Full Rejection <br />Menest Reference Number <br />18b Alternate Facility (or Generate) US EPA ID Number <br />J <br />r..1 <br />LL <br />Fapti s Phase <br />In <br />18c Sigrrabue of Alternate Facility (or Generator) Month Day Year <br />Q <br />z <br />Hazardotis Waste Report Management Method Codes (i a, codes for hazardous waste treahmnil, disposal, and recycling systems) <br />019 <br />1 <br />2 3 <br />4 <br />E <br />20 Designated Facility Owner or Operator Cei4ficabon of receipt of hazardous materials covered by the memfest excegt as noted in Nem 18a <br />YFed SgrraW2 Day Year <br />,7 gnynn <br />r(nyn- av I <br />[I <br />EPA FM 8700-22 (Rev 3-05) Previous editions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (IF MQUIKtU) <br />