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L Ell L. S11i <br />Please print or type. Form Approved. OMB No, 2050-0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1, Generator ID Number <br />2. Page <br />3. E eva Rpfpase?h 4. <br />[007439819 <br />Manifest Tracking Number <br />SKS <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generator's SiteAddress (ff different than mailingNpddreqs) <br />1ti3ektfin Delta Rvflrt <br />1493io W Highwaay 12 <br />i,11D I <br />Generators Phone: <br />6. TTRM! f �'PP. LTINI INC U.S. EPA ID Number 11 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />D.S.I.Ail., HARBORS EAV 'EVC, 1W,, <br />8. Designated Facfflty Name and Site Address CLEANHAIRYMURS SAN 3019E U.S. EPA ID Number <br />1023 -AEARVESSA ROAD <br />SAN JDSE a) <br />CV41) 0 5 9 4 '343 41, Vi <br />Facility's Phone: .1 1 <br />ga. <br />9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <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 />Wt-fvol. <br />NON IRMA, HKIZARDOU,17, MRSTF.' SQLT-m-5 <br />1..Fjjjq3CRRAG <br />MYORL <br />D M, <br />P <br />C2, 2 3 <br />pEj-pr <br />N <br />2. <br />LU <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information T 5DA S14,'3054 C"SU ll <br />R4H retal-ned b,#qernerator o--� ency 'author i, <br />—01i Ilii t ial tr-pinsgortfsr �rt add ay- ubst it ut g zn1d 1 t is RJ trij,5taurt erc.+ ;,n unor ?; ol-I s hehA <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 naffie, and are classified, packaged, <br />marked and laboled1placarded, and are in all respects in proper condition for transport according to applicable international and ristonal governmental regulations. If export shipment and I am the Primary <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 (6) (if [ am a small quantity generator) is true. <br />Generator'sroes Printedffyped.NaTe Signature rj Ro.Wh ay Year <br />–J16. <br />P- <br />International Shipments <br />El import to U.S. ElExport from U.S. Port of entWexit: <br />91 <br />Transporter signature (for exports only): Date leaving U.S.: <br />ad <br />LU <br />17. TransoprorAcknowledgmant of Receipt of Matarlafs <br />Transporehl Pdrited/Typed Name Signature - Month D Year <br />0 <br />A <br />U) <br />m <br />Transporter 2 PrInted[Typed Name Sljnature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space 1:1 Quantity El Type F-1 Residue El Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />ri <br />Facility's Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />!R <br />I 2E <br />.T <br />en <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />C3 <br />1 <br />1 2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />