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Pleasd print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 11z Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST ii 1 t i 15 1 4 7 8 7, 1 i 800)4 r'.4--q3f) 00836945(o J J K
<br /> (yen jratp(s NImerandd ry�'�ixinn',p d.rgSps n x #T t c� Gef�f+iaV. S1tg AddLQ6 (different than mailing address)
<br /> r!P Yc r5!`•1��+`i.dP iyv;A f14f �.iiV �.MFtl':.j,l2YFF Ft.4_ri�'d! 9•TF 1_t
<br /> ?. 4)y, 1.0164 ?�`(;P.r 9 q3q 1.51-CIP N TRORNsRION RT) TV)7 CA g524.
<br /> Generator's Phone: -86 ,t =ADP--7488
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> "AI-IT CQN Tf A PA7Aki"'S i R`stT£ ti ,'AP0,,-)02.lg0.2.;
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> �'.-ror.1Si a"'r. `34; ,Y-T,{tt-! s.Tf^
<br /> [6:30 W, 11th St. Long prh; CP. 14OM 3
<br /> Facility's Phone: "562"+ 432-54"4
<br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit
<br /> HM and Packing Group('d any)) 13.Waste Codes
<br /> No. Type Quantity WLNoI.
<br /> Ix
<br /> Vol tj
<br /> z 2.
<br /> w
<br /> 0
<br /> 3. KL:FtF:NCip was`!F.w
<br /> urs GOSAL.'r1tE,g7'l,.t AS Rt:L'Ei vFD,HAVULED AND STORED
<br /> '✓-'Sias ENT C-R CRUS9yy----. i
<br /> CL,4v" TL'f}fi::d, &UVF7:7t7N.INC. PER FOR SUBSEQUENT OI'T'S
<br /> ;}rz L•"YY1. a)'TT2 DE1AR71,lENT OF TOXIC 511E T FACIENT U
<br /> +tONWt:t?"!'AL'FROTF,� �.. ST ND
<br /> 41,ZE.R�;Lt,AND 'ON ANJ).FTr'ct4£R) A ANCE wt7T{7}iC
<br /> STAT - REG YUTIU.NS. CR pSay (.T OF 1976 TOGEn W PROVISIONS0
<br /> ,1=FtMlTS TOA g, 0.V� .
<br /> +r`CORDINGLY 1.71lE REFERENCED WAST$ '`IYTN H.tS AI-L OF AFFLFCABLE -_,. ,-
<br /> ANG ALL TI1E WASTE I{AS BEEN NECESSARY
<br /> HA
<br /> 14 Special Handling Instructions and Additional Information r
<br /> vt, g� - APPW.-A-Af, 1 �+ 'A`
<br /> ' a Y ?s� 11sJR k'NRRC�-Fef'x.V t'r€3 `i"AC'.`P
<br /> RTT,r, F��7f'' CAT,- A.., CW :Ysi^tMP°C -
<br /> 15. GENERATOR'SIOFFEROR'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,
<br /> marked and labeledlplacarded,and are in all respects 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 consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifd am a small quantity generator)Is true.
<br /> Gen torslOfferorsPrintedlTypedNamegnature Month DayYear
<br /> »:
<br /> �, 151 International Shipments ❑
<br /> F= Import to U.S. ❑Export from U.S. Port of entrylexit:
<br /> Z Transporter signature(for exports only): s Date leaving U.S.:
<br /> w 17.TransporterAcknowledgment of Receipt of Materials
<br /> Transporter)Ennted/Typed Name Signature y---- Month Day' Year
<br /> a fi rx,
<br /> N
<br /> Z Transporter 2 Printed/Typed Name Signatures Month Day Year
<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space
<br /> ❑
<br /> ,g ry � ❑ Quantity �. � ❑Type ��� Residue L1 Partial Rejection ❑Full Rejection
<br /> 4 {fly,A
<br /> -. <.£ ^dam.•,_ ,cr,+S�,, J; ick -2 F d xi
<br /> Manifest Reference Number:
<br /> 18b.Ntemate Facility(or Generator) U.S.EPA ID Number
<br /> Zi
<br /> U
<br /> Ili Facility's Phone:
<br /> w 18c.Signature ofAllemate Facility(or Generator) Month Day Year
<br /> a
<br /> z
<br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)LU -
<br /> � 1, 2. 3. 4, '
<br /> 20.Designated Facility Owner or Operator,Certifiradon of receipt of hazardous materials covered by the manifest 1kcept as noted in Item 18a
<br /> PrintedfTyped Name , j Sign t �(7 Month Day, Year
<br /> t. .a
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR
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