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<br /> Please print or type.(Form designed for tise on e ite(i2-pitch)typewriter.) Form Approved,OMB No.2050,1039
<br /> UNWORM HATARDOUS 2.Page 1 of .3:Emergency Response Phong d,Manifest Tracking Number �(
<br /> GI)l..u,00 14 6,ai k'1 1. 11-8000-466'-V r1,74 �I\�
<br /> WASTE MANIFEST 1.GeneratoriD`N mbe r
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<br /> 5.Generators Name and MagmgAddress Generator's Site Address(if different than mailing.address)
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<br /> Generator's Phone: ''}i.f "fi<+•;t r,
<br /> 6.Transporter l Comilany Name t U.S.EPA ID Number 5r
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<br /> 7,Transporter Company Name U,S.EPAIDNumber
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<br /> U.SEPA 10 Number
<br /> W RRV i) y IOK)8.Designated Facility Name and SileAddross t K
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<br /> F"qNl JOSE 1315.113-11
<br /> Facility's Phone:
<br /> ge• 9b.U.$.DOT Description(including Proper Shlp)ing Name,Hazard Class,ID Number, 1Q.Contatnare 11.Total 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity Wf.No6
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<br /> 14.SpeeiafHandiii instructions and Additional Ink rmatiin 67087 '32 79 3 F,:;
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<br /> 15. GEN ERATOR'81OFFEROR'S CERTIFICATIO :i ereby declare_thatlhe contents of this consignment are fullyand accurately described above by the propersh(pping no a,and are classified,packaged,
<br /> marked and labeled/placarded,and are in all a spec s 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 consiglnmc nt conform to the terms of the attached EPAAcknowledgment of Consent.
<br /> rUlythat the waste minlmizaUon statement f enti'ied in 40 CFR 262.27(a)Of l am a.large quantity generator)or(b)(111 am a small quantity generator)Is true.
<br /> y enerator's10Jf, r Anted/Typed Name signature h — Month Day Year
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<br /> r 16,International Shipments
<br /> El Import to is, El Export from U.S. Part of entry/exit:
<br /> Transporter signature(for exports only): I Date leaving U.S,:
<br /> 17.TransporlerAcknowiedgment of Receipt of Male'ls
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<br /> Trans p tter 1 PrintedfTyped Name Signature ; Month Day Year
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<br /> Q TtanWohiir2 nniedrryped Name Signature ' Month Day Year
<br /> 18.Discrepancy
<br /> 18a,Discrepancy Indication Space Quen ty Q Type ❑Residue ❑Partial Rejection' ❑Full Rejectlon
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U13,EPA ID Number
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<br /> uQ Facility's Phone;
<br /> LU 18c.Signature of Alternate Facility(or Generator) ( Month Day Year
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<br /> v19,Hazardous Waste Report Management Method' odes(i,e„codes for hazardous waste treatment,disposal;and recycling systems)
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<br /> Li20.Designated Facility Owner or Operator:Cerlific±notreceipt of.hazardous materials covered by(he manifest'except as nded in Item 18a
<br /> Pfintedrryped Name Signature Month Day Year
<br /> EPA Form 87Q0.22(Rey.305) Previous editions ae o' 'solete. GENERATOR'S INITIAL COPY
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