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D-TSC . E14723 . 19�5I <br /> Please print or type. Farm designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergently Response Phone 4.Ideniicat Reding Num r {{++ pp C <br /> WASTE MANIFEST C}11[11at1�>,11!r5f3 ► i�19�uL1l�i,1 1M+:'! �. la D f <br /> 5,Generator's Name and MaillngAddress Generator$Site Address 10 different than mailing address) <br /> Wk.; i VAN:D(}UFk1UL <br /> W21 N BROADWAY <br /> Genemtor'a Pho&r)f#,X44-ws'. f <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> rrlh+fl!rfiJVP*'4VALL1-.Y WA,•.M CAL.VU. CAR41412MIM <br /> 7.Transporter 2 Company Name U.S.EPA iD Number <br /> t:'Ot,HICYCLIz bPl-.CWJ Y WAS I Ii:SOLUi K*&,),. mm%awl it <br /> 8.Designated FaciNty Nome and Site Address U.S.EPA ID Number <br /> o1.81131:NIURY L"VIftC7TSOdiERVAL M13M>I W,1414VAtAA1.1, tl<vtakll#t1t�'R.� <br /> F840!a Phones Iiv'IN P..�1.010 ll <br /> JI ga I 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 19.Total 12,Unit 13.Wssia Codes <br /> No. type Quasi ttr INLAM. <br /> 1 r <br /> LV%4 P1 t'A I tea'Af►f'tr"!11..9 WPj$;tF A01 If 1 AA*,;C)Rf%FNT,0111t,nil 1 I rAf 1614 P <br /> rxi#6�yrr:l. <br /> 2. <br /> W <br /> [7 <br /> 3. <br /> 4• <br /> 14.Special Harrel ing Ineirudlons and Additional information <br /> 11HO1"fi.F.0WILVlr24.01 011LY tliftI 1:ft("J k71 <br /> 1:r�•:�c��1�r;r t;c�vrAc:r I.Afittir <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accuratelydesplbed above by the proper shipping name,and are classified,packaged. <br /> marked and labeled/placarded,and are in all respells in proper condition for transport according to applicable Intemailonaland nagonet governmental regulations.If exparl shipment and I am the Primary ' <br /> Exporter,I cerlify that the contents of this consignment conform to the lemma of the attached EPAAcknowledgmenl of Consent. <br /> 1 eertiry that the waste minimization statemeal Ide milled In 40 OR 262,27(a)(if I am a large quantity ganaralor)or(b)(if I am a small quangly generalor)is true. <br /> GoneratorsPOSeror'sPrfntedfrypedHonig Signature 7 <br /> Day Year <br /> .J 18.Intemational Shipments '�^""" <br /> ❑Import to U.B. ©Export Som U.S. Part o0tlVylexlt: <br /> Trensportarsignature(for exports only): Datelaaving U.S.: <br /> 17.TreasporterAclmowledgmentof Receipt of Materials <br /> Trans, 1 P{rinntedffype8 Nam SIg eture /� Month Day Year <br /> Transporter 2 Pdrne"ped Name 1SIg6tUf6 11 Math Day Year <br /> 18,Discrepancy <br /> 18a,Discrepancy Indication Space ❑ quantity ❑Typa ❑Resktua ❑Partial Rejection ❑Full Retec9on <br /> Manifest Reference Number. <br /> 18b.Alternate Facility for Generator) U.S.EPAID Number <br /> ..r <br /> Facility's Phone: <br /> W 180,&gnature of Alternate Facility(or Genarat Month Day Year <br /> Q " <br /> 10.Hazardous Waste Report Management Method Codes 0.e.,oodes mor bazardous waste treatment,disposal,and recycling systema) <br /> 1' 2' �° Notice:State of California requires <br /> 20,Designated Fodlity Owner or Operator Certification 0woelpt of hazardous materials covered by the manifest awl as holed In Itnerator to photocopy and lnaii to <br /> em 18a <br /> ge <br /> PrintedlFyped New 5lgneture DTSC with 34 days: <br /> p,p Bax 400 <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. Sacramento,CA 9SS12-0400 <br /> 13096.1959 r GENERATOR'S INITIAL COPY <br />