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Please print or type (Form designed fop use on elite (.12 pitch) typewriter.) "l Form Approved. OMB No. 2050110039 UNIFORM HAZARDOUS 1 : Ge e�ator ID Number a r �+ 2. Page 1 of 3 Emerg �nc�)Resgonle44 p�oe 4 MNITa infest Tracking Number WASTE MANIFEST R 1_ CI } v ? 1 t ( ; g t � r 1 ti Aft I 5. Generatgrs �I�ne aind.f laming �,. r s - n r _ �' Generator s,Site Address (if different than mailing address) t:. ne o j.ArJ JE81 E RN NIO'l F ,�'b 3 t1. 5. 1 R . 4 , t3ox alis {V'AN T CA GRti 5533 i ' ; > tit ' tJ� iii"t t. AVE" r f '.•' 3 k4k1 4�i,'tNTEt F� Cc A 95 Generator's Phone: 6. Transpor eclU.S. EPA I J tT9T. ?j)I ON tt N7'AL SF RVf OES ,DDD Number_ 3 G � 7 , Apple 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Ej it U.S. EPA ID Number 5375SN�GIJT AVC: NUE LOS A14GFLEy OA 900 iF3is +ni ?s t,) {i ' ','_? tl :'< n :i Facility's Phone: } � 3.5t3tJ ga 9b. U.S. DOT Description (incl ding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13, Waste Codes HM , and Packing Group (if any)) Nov Type Quantity WLNoI. 1 , \ C ` -tide F� 3i�..61 L1� +,FS A�7 l:. , : 1 _€t� + alt, 7 ;1iJ .€ .1.. •• 9't, ' G: '!Y d" IS. 1'.9C:a ; ;Z.rji �0 x rill ) D ibT 9 Fall i Z 2. W (0 30 r 14. Special Handling Instructions and ditional Information , . CI�stE C I~ I�L;� u+��l�l� i � -R n 0c n aAl7 rf �{ EIVIxI FS �OG1 y4 4.. Ou fP�tf Rfi , r � f3 i : 73. PROFILE OFILE A rt31 AP ,t !3;_4`' 3 CDtt 7 rf & tom �t� ? ` 1"R:i'::; ' PrtJ 0tIJ �"� iii '° AE' €� f?OPf�I/a'( E' F� E' F C) !' !i?_ >', C� f I Cl" VE EQUI ' I'r4t=NT wll om r a r 15.� GENERATOR'S/OFFEROR'S CERTIFICATION: . I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and"are classified, packaged,, marked and labeled/placarded( a are in all respects in proper condition for transport according to applicable internatiQpai and national governmental regulations. If a tporf shipment and I am the Primary Expo)ter, I certify that the content of this consignment conform to the terms of the attached EPA Acknowledgment otf Consent, I certify that the waste minimizatio i statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (i ) if"I ama Smali quantity generator) is true, Generator's/Offerooes Printe Ryped N� a Signature C ., i " k j' Month Day Year MIS 16. International Shipments p Import to U.S. ❑ Export from U.S. Port of entry/exit; all ZTransporter signature (for exports only Date leaving U.S.: W.. 17. Transporter Acknowledgment of Rec 1pt of Materials H Transpo er 1 Pdntedfryped Nam Signal ref '' � !;r Month Day Year / I . d 1 ,+ f / lr 4" �.. r t�fj / ri' vIll fes ' 1 •1,, rrr ' ;r,?{`r K�r,1 ` /f l.s r% r! % Gtr to Month Da Year Z Transporter 2 PrintedflIl Name Signature y a . 18. Discrepancy 18a. Discrepancy Indication Space ❑ ' Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number FFw _J V Facility's Phone: I WINE w 18c. Signature of Alternate Facility (orGenerator) Month Day Year t a . z 19. Hazardous WasWRepod Managem Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) 3. 46 f f t 20. Designated Facility Owner or Opera or: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a t Month Day Year Printed/Typed Name � Signature17 If l ILI CY TO GENERATOR Form 8700- 05)22 (Rev. 3. Previou editions are obsolete. DESIGNATED FAC