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x <br /> Please print or type. Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator 1D Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST C.ALq. e21_132 1 I'll 6.-371-5741 020 14+679 JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> faA�; ll li <br /> 16TSE IIE LEWIS OR <br /> STOt;,ii€RA4,Ch <br /> Generator's Phone'%W-#1W <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> li f•„Pi'•.ftROMWEsi <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site AddressR E[db4Rt�hl14#t=I�TJ SFT i� "s I U-S.EPA ID Number <br /> 1515 S{? WITH Rt'A�R R0. <br /> WEST ISACRPMEW 0,G?CC 91 <br /> Facility's Phone1& 71 547 <br /> 91. 9b.U.S.DOT Description.(including Proper Shipping Name,Hazard Class:ID Number, 10.Containers 11,Total 12,Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtIVol' <br /> 1. KON RL;R t HAZAll AVAST <br /> � f _ <br /> LU <br /> LU <br /> M 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Ell <br /> >43,tti#i131-liMf2 a iHCt JL0 BE MAPED A140 li APP)i PPI <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and ai 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 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.pf Consent. <br /> I certify that,the waste minimization statement idenfified in 40 CFR 262.27(a)(if I am a large quantity generator)or'(l1)(ifI am a small quantity generator)is true. <br /> Generator'slOfferoys PdntedlTyped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> cti 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O , <br /> a <br /> z Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> a <br /> F <br /> 18.Discrepancy <br /> 189.Discrepancy lr kation Space ❑ quantityyp <br /> ❑Type Ll Residue ❑Partial Rejection Ful[Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ;� Facility's Phone'. <br /> C3 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <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 18a <br /> PrintecifTyped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL.COPY <br />