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PIK SH",Piz <br /> Please print;or= pe.(Form designed for use on elite(12 pitch)typewrites) Form Approved.OMB No.2050.0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Einer ency Res onse Phone 4.Manifest Tracking Number <br /> (HAZARDOUS ^• ►� � 17 <br /> i1A 7EMANIFF�,, j�tJ'()l*>�Ll 0221 SKS <br /> 5.Generator's pKe and Malting Address Generator's Site Address(if different than mailing address) <br /> E - o&,�te �r�� r Wtsalt? ► �y <br /> t 3 tat. SZ 0 � 9�$) A-T T 4 SP �c � / ✓� a ( UL t`S �y1 7 <br /> C 15 <br /> pidtaPj �`2C� <br /> Generator's Phone: tai ._ Sq ' - 6 53q 1 o <br /> 6.Transporter 1 FECompan Name U.S.EPA ID Number <br /> �•KM TYN SYSTEMS INS <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> OLEAN HARBORS ENVIRONMENTAL SERUCES INC <br /> 8.Designated Facility Name and Site Address "HARBORS WILMINGTON Lr U.S,EPA ID Number <br /> 1737 EAST DFNNI STREET <br /> ' WILMINGTON TON CA 90744 <br /> Facility's Phone: <br /> ga 9b.U:S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NON-RCRA HAZARDOUS WASTE, 601-ID DM Pe'3 <br /> 0 (OIC. FILTERS) <br /> 2. <br /> w <br /> -3. <br /> t <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 8 fi <br /> A> 1 <br /> P-4®HN , `R N Y1ALI AS -46'-17 ( f T I?GLIM TO RE IN I IrENSED BI i <br /> R 111ARETFIRS AS Will'Pt"UARY <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 labeled/placarded,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 EPAAcknowledgment of Consgnt.'/ <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i a,/a small quantity generator)is true. <br /> Generator's/0 ror s Printed/Typed Name Signature, Month Day Year <br /> l +�.yam} f. s <br /> 16.Internal Fnal Shlpmnts 1 <br /> F— ❑import o U.S. ❑Export from U.S. Port of entry/exit: <br /> 2 Transporter signature for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter Printedfryped Name Signature Month Day Year <br /> 2 Tra r 2 Printedil ped Name S' lure Month Day Year <br /> Q <br /> H <br /> 18. screpancy +; <br /> 18a.Discrepancy Indication Space E quantity, 1:1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 4 <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 0,s <br /> J <br /> V , <br /> LL FacilitysPhone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> us19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal;and recycling systems) <br /> 0 1, 2: <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> 1A,1 �y�r <br /> EPA Form 8700-22(Rev.3-05) Previous editions are ob tete. �A`f$ DESIGNATED FACILITY TO GENERATOR <br /> i <br /> . sat 56777 ��G q Z 117 <br />