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Form Approved, OMB No. 2050-0039 <br /> Please print or type. 2. Page 1 of 3. Emergency Response Phone A. Manifest Tracking Number p p <br /> UNIFORM HAZARDOUS 1. Generetbr ID Number M9- � ® 19515112 �JJK <br /> WASTE MANIFEST �" ® � <br /> � M Generators Site Address (lidilfemnt than malting address) <br /> 5. GeraeLalgr' K6f3 I T SERVICES <br /> 7679 LOME GTRFET <br /> STMKMM CA 95 <br /> Generators Phone: 2 0 0 2 3 4 a 0 1 a 5 U.S. EPA ID Number <br /> 6. Trans oRe r 1 Company Name ERVI S G A R 0 0 0 2 6 9 5 4 8 <br /> U.S. EPAID Number <br /> - -- <br /> 7. Transporter 2 Company Name <br /> U.S. EPA ID Number <br /> 8. Desi led Ci it a lag d ess <br /> WSW � , l6S� KETTLEMM HILLS <br /> 35251 OLD SKYLINE ROAD <br /> KFT MEMAN CITY CA 93239 0 0 0 6 4 6 4 1 7 <br /> Facililys Phone: sum ��"0711 <br /> 10. Containers; 11 . Total 12. Unit 13. Waste Codes <br /> 9a 9b. U.S. DOT Description (inducting Proper Shipping Name, HazaN Class, ID Number, No. Type Quantity Wt.NoI. <br /> HM and Packing Group (If any)) 9 <br /> 1. (idea'S4RCRABtIs ROOMSI D 20 <br /> o Do 9 Cid <br /> 2. <br /> 3. <br /> 4, <br /> 14. s�e�'atl�Ydhjns8gbmbM1d 1lionj8grm t rt4BER 122- 15101 0010—JOOOI <br /> J� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Thereby declare that the contents of this consignment Irefully and accurately described above by the proper shipping nam e, and are classified, packaged, '.. <br /> marked and labeledipiacarded, and are in all respects in proper condition for transport according to applicable Iaternationaland 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 Certify that the waste minimization statement identified in 40 CFR 262.27(a) (it l am a large quantity generator) or (b) of] am a small quantity genera) is hue. Month Day Year <br /> signaturel �y <br /> Generatorsl0fi rer; Pri ted7Cyped Name � � 0LLY ',.. <br /> 16. International Shipments ❑ Import to U.S, ❑ Export from.U.S. Part of entry/exit <br /> It <br /> Dale leaving U.S.: <br /> Transporter signature (for exports only): <br /> Ke. 17. TransporterAcknowledgment of Rel of Maledals Signature <br /> - Month Day Year '.. <br /> Trans 1 Printed/Typed Name I� _ <br /> - 'I nam <br /> Manch Day Year <br /> Transp er PrinteWlY ed Name <br /> 18. Discrepancy '.. <br /> 181 Discrepancy Indication Space ❑ Type ❑ Residue ❑ Parts) Rejection ❑ Full Rejection <br /> ❑ Quantity <br /> Manifest Reference Number: <br /> U.S. EPA ID Number <br /> r?'., 18b. Alternate Facility (or Generator) <br /> J <br /> U <br /> Facility's Phone: Month Day Year <br /> w 18c. Signature ofNternate Facility (or Generator) <br /> Q <br /> 19. Hazardous Waste Report Management Method Cm I, (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 4 <br /> Go <br /> 0 1. <br /> 4 3. <br /> 20. D�`a�F�ty Owner or operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Y - Years <br /> Prime /Typed jme Signature 2 � )`F1' <br /> ®��(��A��9 ���)�(�v TO ��A'� elaMANIFEST BMW <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />