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Please print arty Farm Approved.OMB No.2050-0039 <br /> U FORM RpQUS 1.GeneFater ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WITS MANIFEST `? A 9 7 8 2 —Idim <br /> 0197 , �� <br /> 5-GeneratVs Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> CaRmn <br /> K(r 0.10 Tracy MWE <br /> Gene�aPs Pone.X376 <br /> 6.Transporter t Comp _ • 9 U.S.EPA ID Number <br /> 7.Transporter 2 Company Name Wr U. . P I umber .. <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Fftr Rservile S.1i;IG.tHerrW TSDq <br /> 180 W .Aim VOTHM <br /> CA 92316 <br /> Fa Gli s hone. A. P% 1% 0 1% <br /> 9b.U.S.DOT Descri bon(including Pro Shipping Name,Hazard Class.ID Number, 10.Containers } <br /> 9a. P C 9 P� PP 9 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type 9uantity Wt.Nol. 13.Waste Codes <br /> d <br /> a 2. <br /> LLJ <br /> 3. <br /> 4- <br /> 14.S-pecfal Flarrdlfng Instructions aW Additional InloirmaWn <br /> One or mode of the material listed an this may <br /> h I - fl Be recycled as aHernative daily cover(ADC)or other <br /> 9. XI til Method which.uses the material iii Or on the land. <br /> 15. GENE RATOR'S10FFEROWS CERTIF CATION: 1 hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are Classified,packaged, <br /> marked and fabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations.If export shipment and i am the Primary <br /> Exporter,i oertity that the contents of this consignment conform tote terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if 1 am a small quantity generator)is true. <br /> Generator'slORe is P60edfTyped;Nle Signature — Month Cray Year <br /> a 16.International Shipments <br /> i— ❑EJ Import to U.S. &pori from U.S. Part of entrylexih <br /> ? Transporter signature(fQr exports only); Date leaving U.S.: <br /> ' 17.t9tpDrW AdT"edgment of Receipt of Materials <br /> LTJ <br /> ;2 Tr ofLI <br /> V1 _fer 1 PrintedfTyped Name 5ignatu , Month Day Year <br /> a <br />-, ii <br /> -p.. .i}- 4 / lVf <br /> i Transporter 2 Pdntedffyped Name 5 re <br /> Month Da Year <br /> 18.Discrepancy r <br /> 18a.Discrepancy Indication SpaceFM <br /> n -UM <br /> ❑ Quantity ❑Ty i,�i � i`1 {;epltr(]e {�I����`S Pa tial Rejection ❑Full Rejection <br /> " TI- E A. <br /> #p 9 44481 NAS ttr�rr , T AA SkJJPPM <br /> 18b.Atterna .. armest-RefereoceNumber..:r,., — <br /> J le Facility(or Generator) �� <br /> --�— U.S.EPA)D Number <br /> tai Faulity's Phone; <br /> LLu 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> Z <br /> 13.Hazardous Wasle ReportManagement Mefhod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> CIO <br /> 4w7 t 2' 3' 4. J <br /> 20.Designated Facility Dwner or Operator;Certification of rec, f hazardous materials covered by the manifest except as noted in Item 180 ` <br /> PrintedlT Name Signature Month Day Year <br /> Lit 12(�, 118- <br /> EPA Form 8700-22( ev. -17) Previous editions a ete. <br /> �J <br /> tDE=S1GNATACILITYT0 GENERATOR <br />