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Please pri,ft(It.type. Form Approved.OMB No.20160-003,11 <br /> Number Emergency Response Phone fl', <br /> Generator I 6 <br /> Generators Name and Adriiss�_ <br /> Generator's Site Address(if different than mailing Wcidlrei._)_ <br /> Generators <br /> aloes ph�cna.,• <br /> 6.Transporter Coi;pany Wine- <br /> U.S.EPA ID Number <br /> 4, <br /> 7.Transporter Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and'SICe Add re a s <br /> U.S.EPA ID Number <br /> Facility's Phone""' <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12.Unit <br /> Nom' Type Qua <br /> HM and Packing Group(if any)) 11.Total <br /> Wt.Nol, 13.Waste Codes <br /> 7 <br /> fa, <br /> R <br /> LU <br /> 2. <br /> LM <br /> 4. <br /> qg. <br /> 14.Special Handling Instro6tiond and Additional Information <br /> V <br /> 15. GENERATOR'StOFFEROR'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 labble'd/placarded,and are in all respects In proper condition for transport according to applicable international and national gdv6mmental regulations.If export shipment and I am the Pi-Impry <br /> Export[br,I certify that the contents'of this consignment conform to the terms of the attached EPAAGknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 GFR-262.27(a)(if]am a large quantity generator)- . an rator)gr(b)(Ifl am a small-clupittity generator)is true. <br /> Generators/Offeroes Printed/Typed Name Signature R, <br /> Month Da <br /> Year` <br /> -1 16 International Shipments <br /> 0 Import to U.S. ❑Export from U.S. "4- <br /> &64'a of entry/exit: <br /> E; Transporter signature(for exports only): Date leaving U.S.: <br /> pe 17.TransporterAcknowledgment of Receipt of Materials <br /> Uj <br /> ra° Transporter I.Printedflyped Name Month Day Year <br /> 1? 4, Signature <br /> C) <br /> Mon <br /> _Y &Y_ <br /> ;_1 TrarXAppi eT2'PfIh1ed[Ty0d Nam, <br /> �___-Slignatura Mo5th -Day <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Raj.ec'tlori <br /> 18b.Alternate Facillty.(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> • <br /> Facilitys Phone: <br /> 1. 186."Signature <br /> bf Aff6fnate Fadillty(or Generator) <br /> Mon Fh Day Year <br /> 19,Hazardous Waste Report Management Method Codes(Lal,codes fof lraza*rdout waste treatment,disposal,and recycling systems) <br /> 2. Notice: State of California requires <br /> generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certification ofreceipt of hazardous%m-aterials'covered by the manifest except as noted in Item 18a DTSC 1,1AZY)30 days- <br /> TIntedqyp,1-Nam. Signatur�_P,o 80,�4.fj'g <br /> A Form 8700-22(Rev.12-17) Previous,editions are obsolete. <br /> 6 NERVATIM:'S INITIAL GM <br />