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fOVfi3+4 �7 „ •. <br /> NJ <br /> Please print or type, (Form designed for use on elite (12-pitch) typewriter.) _ Form Approved. OMD No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. Genemtor ID Number 2. Page 11 -. E- ergency Response Phone 4. Manifest Tracking Number �p®�y® <br /> WASTE MANIFEST L ,l . ii �1 Q 5 9 5 ' ^ — 1 011180905 ® ` <br /> 5. Generators Name and Mailing Address Generators bile AddresS grditferentthan mauling address) <br /> AP AMARK <br /> 7679 S, LONGE -ST, <br /> STOCK'l ON CA 95206 <br /> Generators Phone: ( 909122A 1 ,` <br /> 6 spoiler l Company Name U.S. EPA ID Number <br /> rii ISA c,{e,0d ;r prb�i`�OS£S `J1C7 <br /> U.S. EPAI4 Number <br /> 7. Transpoder2 Company Name <br /> eDty Name and SiteAddress US. EPA ID Number <br /> CHEMIC❑. VNASTE MANAGEMENT, INC. dA T €i [9 6 6 4 6 1 1 7 <br /> 35251 OLD SKYLINE ROAD <br /> KEI IILEMANCITY CAN 93239 ' <br /> FaciffIs Phone: 91 __ 9 10 '. <br /> go. 91b. U.S. DOTDescdption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes <br /> HM and Packing Gmup (if any)) No. Type quantity W1Nol. <br /> ce® 1' NON RCRAHAZARdCUSYMASTESOLID � �m � ® ?� <br /> C�68852 <br /> w 2, <br /> 3. <br /> 4. <br /> 14. Special Handling InslrllChenS and Additional Information <br /> 1 . CA@08852 CHEMTREC CON T Rr`4CT # CCN24 '117 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, <br /> marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowledgmenl of Consent. <br /> I certirythat the waste minimization statement identified in 40 CFR 262,27(a) (if I am a large quangty generator) or (b) (if I am a small quantity generator) is true. <br /> Month Day Year <br /> Ge torslO^Her/o�ts PnntedRy/ped Name - 7 Si <br /> gnalu <br /> J 16. International ShipmentsImport to U.S. =t ❑ Export from U.S. Pod of entry/exit: <br /> r ❑ <br /> Z <br /> Transporter signature (for exports only): - Dale leaving U.S.: <br /> W 17. TranspoderAcknowledgment of Receipt of Materials <br /> i Prinledlfyped Name S(g atu NNNNNNNN—Womth Day Year <br /> Tran over <br /> aTransporter 2 Pnntedl typed Name Slgn ure Month Day Year <br /> tr <br /> 1-- <br /> 18. Discrepancy j <br /> 18a. Discrepancy Indication Space ❑ quantity El Type ❑ Residue El Partial Rejection El Full Rejection 3 <br /> Manifest Reference Number. a <br /> 186. Automate Facility (or Generator) - U.S. EPA ID Number <br /> J <br /> U <br /> Facilitys Phone: <br /> w Inc. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> 19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardouseraste treatment, disposal, and recycling systems) <br /> 3, , <br /> ® i 2. 4 i <br /> 20. Designated Facility Owner or Operator: Cedifomilon of receipt of hazardous materials covered bythe manifest except as noted in Item Ise <br /> IN <br /> Primed(ryped Name <br /> Month Day Year <br /> . 03 I CA I I (Ne <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions areohsonne. DEMONATED EACI61TVTO DESTINATION STATE (IE REQUIRED) <br />