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Please print or type.(Form designed for use on elite(9.2-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Nage 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST - i ti ` l ?i c''=-iiia:• <br /> 0014,14144 VES <br /> 5.Generators Name and Mal firt Address JUN NNUKIJQGerteraWs SheAddrass(if dfiferent than mailing address) <br /> 'KTOIIJ, 95265�2-4F3 <br /> f tJ,l cf 4' t;•1�,;;i�.��t; r l'J�s_.l l-_ -._ �.i •1 J <br /> inerator's Phone: <br /> F, Transporter 1 Company Name _ U,S.EPA ID Number <br /> L,i . ^'�iL(.'FiIIi(_''�Lc:i��.(;'j' p. ] T r =i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number - <br /> B.Designated Facility Name and Site Address `, r -,T;• r;-.., U.S.EPA ID Number <br /> ��F:��I�L_i5 ;�:.�_-s,]'1I�:�.�_:--TIT1':_�s'•r��, <br /> 1 L.C. <br /> 1123 HEN'3I.1 '_F-TREET <br /> Facility's Phone: <br /> t{I!_'1�1bT(=l.if r = i7�iq;fll T f! i ] A i! <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 and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 1' 1It=JlJ y:+`iii�d 13:ALALFRLi-1�:={so WANE S011D, �'--'YJ TdL RKt }:IL", .31 <br /> o _ 7 <br /> - � i Y <br /> Z 2. <br /> W <br /> C7 <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information EF Se-ivil-c - F it, :; r',1jt'.<(i(I s`,i:n ILiL LI '=a <br /> 15. GENEtfATOR'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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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)(if l am a small quantity generator)is true r <br /> Generator's/Offeror's Printecirryped Name Signalur8 Month Day Year <br /> 16.International Shipments <br /> z <br /> ElImportto U.S. ❑Export from U.S Port��ntryrexli: _ <br /> Transporter signature(for exports only): Date B=ooing U.S.: <br /> De17.Transporter Acknowledgment of Receipt of Materials <br /> � Transporler 1 PrintedlTyped Name SlSnature / _ Month Day Year <br /> O <br /> I 8 <br /> a iId'_'WtT a0Iulti' <br /> U) 7ransporler2 Printedfryped Name Signature Month Day Year <br /> Q <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type - 1 Rejection. <br /> T e -].Residue Partial Re ection Full Re ection <br /> Manifest Reference Number: <br /> 18b.Alternate Facillty(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> I FacaiVs Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> as 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 1. 2, 3 4. <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Pnntedrryped Name Sk}nawra,ti Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous ed do s are obsolete. DESIGNATED FACILITY TO GENERATOR <br />