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f <br /> x <br /> PlQase print or type, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number l 2.Page t of 3,Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST s`Q t,3r7sfiJ:'d of 9 11195:r'a FuTr •#y J J K <br /> 5'Generalor'9'Plame and Melling Address Generator`s Site Address(If different than mailing address) <br /> �a9$ Iu•"..��9� �9���-"�1;79�9#ti€. <br /> - <br /> Ganerator's <br /> 6.Transporter 1 Company Name. U.S.EPA ID Number <br /> RA,A!0£v <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA M Number <br /> 11'0 Elk;;T P100%)0. <br /> )0. <br /> 9.,4;;S AttiIVA, 22114,CA <br /> Facility's Phono�M-4WU-7140 <br /> ga, 9b.U.S.DOT Description(Including Proper Shi pping Name,Hazard Class,ID Number, 10.Containers 14.Total 12.Unit <br /> HM and Packing Group(€f any)) 13,Waste Codes <br /> No. Type Quantity Wt.No€, <br /> 1. H,144Mr``°BL OL10 ClR0AP 9€,fil05,4.1,€x0119 f ,a F=° iia? 1101 <br /> pvkw Plum$4 <br /> 2. <br /> u! <br /> C"J <br /> i <br /> 3. <br /> 4.- <br /> I <br /> 14:Special Handling Instructions and Additional information <br /> 212. x(.1}9 'h� �39 : 1a.9att " ? 9'�d19>2f+1E?tt9T .9r <br /> 15.. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the ovntents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects In proper condition for transport according to applicable Internationaland national governmental regulations:If export shipment and I am the Primary <br /> 'Exporter,i certify that the contents of Vs consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I codify that the waste minimization statement Identified in 40 crR 26227(a)(if i am a large quantity generator).or(b((if I.am a small quantity gerneralor)is true. <br /> GeneratorslOfferoes?rmiedfTypedName Signature Month Day Year t. <br /> 16.International Shipments ' <br /> j.... ❑Import to U.S? ❑Export from U,S. Port of entrylexit: <br /> Transporter signature(Tor dxports only): Date leaving U,S,: <br /> 0� 17,TransporterAcknowledgmentof_Receipt ofMaterials <br /> Transporter:1 Pdritedlfyped.pame Signature Month Day Year <br /> CL <br /> zTransporter 2 PrintedfTyped Name Signature.— Mohth Day Year <br /> h <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication SpaceQuantity ❑Type ❑Residue F]Partial Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> 1 eb Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Faculty's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> r19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. <br /> L <br /> 3. 4. <br /> 20.Desighated Facility Owner or Oporator:Certification of recelpt of hazardous materials covered by the manifest except as noted in Item IBa <br /> printed <br /> Fyped Name Signature Month Day Year <br /> EPA Form 5700-22(Rev.12-17) f revlous editions are obsolete. -GENERATOR'S INITIAL COPY <br />