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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> A UNIFORM HAZARDOUS 1 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phona 4. Manifest Tracking Number <br /> WASTE MANIFEST i iSqqr13qZqod 015879194 JJ <br /> S. Generator's Name and Malting Addrs Generator's Site Address (If different than malting address) <br /> 7C"700t L cac L 5 'r <br /> Generator's Phoj 25 4 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7 Transponer2 Company Name U.S. EPA 10 Number <br /> B. Designated Facility Name and Site AddressU.S. EPA ID Number <br /> C.i'Pe AI CAL wA%T'& /AAygP QV PV^Ja9'; J# t <br /> 3szsl oi� to <br /> � ' i . �t ar�3 CA X 3231 <br /> Facilis Phone: CH C III <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 , Total 12. Unit <br /> and Packing an 13. Waste Codes <br /> 9 Grou <br /> HM P (�if Y)) No. Typo Quantity WI.NoI. <br /> 4i <br /> al <br /> ® of CfJ` •Za �/. _.. -._.. ( <br /> z 2. <br /> � ' I <br /> 3 i <br /> , <br /> i <br /> 4. <br /> I <br /> 14. Special Handling Instructions and Additional Information fit. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of (his consignment are fully and accurately 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 international and national governmental regulations. If expoH shipment and l am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a) (if I am a large quanety generator) or (b) (ifI am a small quant) generator) Is [me, <br /> Generator era Prinle y Nage Signature Month Day Year, <br /> ` /�1 IeP <br /> J 16. International Shipments <br /> r <br /> 1:1 MA to U.S. ❑ Export from U.S. Part of entrylexit: <br /> Transporter signature (for exports only): Date leaving U.S.; <br /> 17. Transporter Acknowledgment of Receipt of Materials <br /> iK TmuE2der 1-PrintedrFyped Name Signet re Month Day Year <br /> s/ 0 IS <br /> H Transporter2 PI Iype arae S Month Day Year <br /> h <br /> 4. 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ ResiduePartial Rejection I ElFull Rejection <br /> ❑ <br /> Manifest Reference Number; <br /> 18b.Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> Facililys Phone: <br /> w 18c. Signature ofNternate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Q 1. 2. 3, 4. <br /> 20. Designated Facility Owner or Operator. Ceuifical!on or receipt of hazardous atertals covered by the manifest except as noted in Item tea <br /> Pdntedrfyped Name Signature Month Day Ye <br /> EPA Form 8700-22 (Rev. 3-05) Previous a ons are obsolete. DE�IGNfk�E® FLICIP�I`T - @ Ii�9ATl®N �'PfdYE (IF FTEQUIREDI <br />