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Please print or type, Form Approved,OMB No,2050.0039 <br /> 1 Ge�erploclD,umber "—" <br /> T UNIFORM HATARDOUS 2.Page i of 3.Emergancy Response Phona 4.ManitsstTracking Number <br /> Gt�c. ? l a r�;1r~ t..:F,�r,... iii <br /> WASTE MANIFEST !+(C,~'17 t <br /> 5 Generator's Namo and Matting Address Generators SiteAddrass(ifditterenl Than mailing address) <br /> 21zi 27th 9t'Y <br /> Generator's Phone; 916—i14,4-20525 <br /> B.Tc�r„^arne,. " Compay Nama <br /> LTYrf,iP 1J Sly <br /> ( h(w SU.S., .EPA ID Number <br /> Cff ti0a1120'� <br /> 7•Transporter Company Name U.S.EPA ID Number <br /> CL EPIN 1•s(;r"tG10V6 09 f R1)qh' NT(1!: <br /> 8.Designated Facility Name and Site Address , r t1:S,EPA ID Number <br /> to{��FAN �[H!11,,98Ol��a/�S1A}p�7d/��Jo viz <br /> 1021 D{;.RR'f HS'S't Ti Lii•D <br /> Stant J082 , f,tl `•7';1"33 �. <br /> Facilly's Phone: <br /> qa, 9b.U.S.DOT Description(including Props,Shipping Name,Hazard Class,ID Number, 10,Containere 11,Total 12,Unit <br /> I'll and Packing Group(if any)) No.__. Type Quanliry Wf,Nof. 13.Waste Codes <br /> 0 1 hl 131" ON RRA i�lA A,h'DOUJB 4!f`r.i'1'.� 9 I Yt)sy^' � DH P ri?" <br /> (>��-�1�I��Y >"ka'�(.lL.l"!![ 1•IY�:�tOi''l��tt�Oh'��,� a'��i�. . : <br /> 2. <br /> �a <br /> 3, <br /> d. <br /> T47,87171Handling Instructions and Additional Infor a lo'n <br /> iSJw SU 7 JrYl:li:ff'J?7 CL•ac.'�,7;3::Y <br /> •1I I;i'4kltl, itl l� .t?>7�rG:-�f�f - 'T <"i .rlilu7Kf�'l`1..,G n r� swt retained by genarat tn- norif ria11, <br /> 15. GENERATOR'S10FFEROR'S C RTIFICATION I hnit hat the contents of this consignment are'fully and aecutalely descnbgdlbove by the proper sitipp ng'name,aM are classtfie pa0kaged, <br /> marked and labeled/placarded,and are In all re ecis in proper condition for transport according to.applicable(njernalioneland national governmental regulalions,.If export shipment and l am the Primary <br /> Exporter,I certify that contents of this consig mantconform to Ihaterms of the attached EPAAcknowledgr(,entof ohsbnt. <br /> f certify that the waste minimization statement id h8find'in40 OFR 262.27(a)(if l am a large quantity g@neratoO or:(b) if i e 1 a small quanllly generator)Is true, <br /> e ieratc'a/0fferofs Pdriladffyped Name ` Signature s" Month Day Year <br /> `1 <br /> _j i6,International Shipments �im import i— p ❑Export from U.S. f 3PI. <br /> of entry/64;zTransporter signature(for exports only); leaving U.S.: <br /> W 17.TransporterAcknowledgmentdfFiecelptofMaterials <br /> Transp#01 PnnfedlijpedNama Signature f Month Day Year <br /> Z Transp ri Q yped Name i <br /> a <br /> tin r Month 05Y Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceElQuantity ❑Type YP ❑Residue: ❑Partial Rejection ❑Fug Rajecti0n <br /> Manilest.Refarence Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> u`t- Facility's Phone: <br /> CFHazardous <br /> te Facility(orGeneralo?) Mnnl Day Year <br /> Z <br /> port Management Method Cods(L�,,codes for hazardous waste.trealment,disposal,and recycling systems) <br /> 2 3. 4: <br /> 20.Des <br /> lgnated Facility Owner or Operator:Certification f receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Printed/Typed Name Signature Adonih Day Yaar <br />( r <br /> EPA Form 8700.22(Rev.12-17) Previous editions ar obsbiele: 1 GENERATOR'S INITIAL COPY <br /> J <br />