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Please print or type..(Form designed for use or slit ('12-pitch)typewriter) Form Approved,OMB Not 2050-0039
<br /> UNI ORM HAZARDOUS 1.Gonerator ID Nun or 2.Pago 1 of 3.Emergency Response Phone 1' 006444151
<br /> Manifest Tracking Number WASTE MANIFEST ,_0f,10 4--G.r60 ! L (�n1y;�.,,U,� ...I eQl) ;Jt1�j
<br /> S.Generator's Name and Mailing Address Generator's Site Address(H,dtfferant than mailing address)
<br /> �1,Co AI" 7'i r1 c I � 1f
<br /> >4 " St
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<br /> Geriiirato7s Phono , , ,,, � - •
<br /> 8.Transporter 1 Compan NaMe U.S.EPA ID Number
<br /> Srd!'c 1'Y—x,t..EEN sn i'Em" N,
<br /> 7.Transporier2 Company
<br /> ��Name U.S,EPA ID Number
<br /> 8.
<br /> Designated Facility Name I t r` f'1I �;rdf' +,(" s��L1'''•+l=-t ,,.••F.:;1
<br /> U,S,EPA ID Number
<br /> LEAtl HARBORS SAN Jos:�-
<br /> 021 BERRYESSI-1 ROAD i
<br /> Facility's Phone:
<br /> ga, gb-U.S.DOT Description(including Prop r Shippfng Name,Hazard Glass,IO Number, 10.Cenlainars 11.Total 12.Unit
<br /> HM and Packing Group(if any)) 13.Waste Codes
<br /> No. Type Quantity wuvol•
<br /> 0
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<br /> 3.
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<br /> 4.
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<br /> 14.Special Handling instructions and Additional In rmation
<br /> Tr"I A awf 757591571 '':i"s 3:r1_ ;
<br /> C�h i , . ��"�7�.� aJi -' IFI)�} X00Z33,� ;7
<br /> 15't7GE E bR'S10EPt:f{ 'S CI?TI CRT NN Fere'yd are t aTilid'dontent of hie'wnsi �t e�etfa d a 'ir�t 1' sdribd dbo931i5^ihe p7oWaris(pping name,and are classified,packaged,
<br /> marked and labeledlplacarded,and are in all
<br /> r$speols in proper condition for transport according to applicable internagonal and national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I cerlity that the contents of this cans nm nt conform to the terms of the aftaehad EPAAeknowledgment of Consent.
<br /> I certify that the waste minimization s(atementidenlified in 40 CFR 282.27(a)(iti am a large quantity generator)or(b)(III am a small quantity generator)is true,
<br /> Gonerator'stOhror's Printed lipped a a Sfgnaluro. _ Month D Year
<br /> .J 16.International Shipments
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<br /> i— ❑Impart to L.S, ❑Export from U;S. Port of entry/axil..
<br /> Z Transporter signature(for exports only); Date leaving U.S,*,
<br /> 17.Transporter AcknoviledgmontofReceipt ofmated;Is
<br /> oTransporter 1 Pd ted7Typed Narpe SI Month Day Year
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<br /> Transporter2 Pdnte a tame ' Signature
<br /> Month Day Year r.
<br /> 10,Discrepancy
<br /> i8a.Discrepancy Indication Space � Quanii)y
<br /> I• ❑Type El Residue ❑Partial Rejection ❑Full Rejection
<br /> 18b.Alternate Facility(or Generator) Manifest Reference Number.
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<br /> U.S,EPA ID Number
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<br /> W Facility's Phone:
<br /> w 18c.Signature ofAiternale Facility(or(enerator) Month Day Year
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<br /> 0 19.Hazardous Waste Report Management Method Cedes i.e.,codes for hazardous.waslotreatment,disposal,and recycling systems)
<br /> 3. — 4,
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<br /> 20.Designated Facility Owner or Operator Codification of r ceipt of hazardous materials covered by the manifest except as noted in item 18a
<br /> Prince a Orr Signature �/� Molih Oati Year,
<br /> FPA Form 8700-22(Rev.3-05) Previous editions arlt ab olete• DESIGNATED FACiLITYTO GENERATOR
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