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Please`print or type.(Form designed for use ori elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C14, 0000981779 W :' _]2 :`;. ,U .r _ JJ K <br /> 5.Generators erators Naaribn m�Mailin�g.Address �F_� Generators Site lif different than mailing address) <br /> Generators Phone: 9 ' ... 7 13 9 ` 51 114 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> _fed%K :. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i6wilk i All.sk" <br /> t,)N Beach CA ON13 <br /> Facility's Phone: 30 4=-5445 C ;A 0 0 2 8 4 0 9 0 1 <br /> ga. 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.Nal. <br /> 3,Pill <br /> LLj "ryy�•R SM <br /> LLI <br /> 0 <br /> 3. €+� .' .XA"VXMili Vilii SW(bili CRRAWN" <br /> IDs '°� ! <br /> 4. <br /> 14.Special Handling Instructions antl Additional information PPE Whi—D handl ing 'hTdlate a Weights or volumes are appdroximato y <br /> 41,!J ,lrof-4r tli ' t a 91).3yProftl>e 1111- iV- Project'. 079023--17 WR#21467 <br /> 15, GEN ERATOR'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 Iabeledlplacarded,and are in all respects in proper condition for transport according to appiicable intemational 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(bJ(ifl a'T a small quantity generator)is true. <br /> Generator'slOfferors PrintedfTyped Name Signature x Month Day Year <br /> 16.Intematlonal Shipments <br /> If^ E Import to U.S. ❑Export from U.S. Port of entryfexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> Lu 17.Transporter Acknowledgment of Receipt of Materials <br /> I.— Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a <br /> Z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> Q <br /> 18.Discrepancy <br /> 1 Sa.Discrepancy Indication Space quantity Type J J <br /> ❑ Ll Partial Rejection <br /> Full Rejection <br /> Manifest Reference Number: <br /> H 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> 2� Facility's Phone: <br /> In 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> F619.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> n 1. 2. 3. 14. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in flem 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />