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SSL "Rilft�R0735we <br /> .Please or type.(Form designed for lyse ohlite(12-pitch)typewriter.) Form Approved.OMB No.2050,0039 <br /> ,, <br /> k6km HAZARDOUS Generator.D Number 2.Page 1 of 3. me R s e P 14.ManffeatTrackln Number <br /> PASTE MANIFEST <br /> 5.Generator's Name and Mailing Ad . 0118 6006 FLE <br /> dressCA Generators'Site Address(if different than mailing address) <br /> Ar. <br /> Golden A �1 �TiGat ' <br /> fdost t nfa Rd Rttn Samuel enry 1 A 1` Stanford R� <br /> CA 95377 Attn �.e �° Saba <br /> Ge/em&toe,8Phone: `; 7 CA 95377® � <br /> 6.Tr ns rler Com ny Na"e U.S.EPA ID Number <br /> FE M Sys I, TXROOMIM <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated facility Name and Site Address _. <br /> AM Y"KLEEN i�ALIFO TA u.s.EPAlDNurnber <br /> 68",SMITH AVE® <br /> WE WARKg CA 9 <br /> lrB�l� IT1 <br /> Facility's Phone:., <br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.� it <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wl.Nol. <br /> o . 1: �� ED—R CTt D HAZARDOUS _TEE LICUID �� TT e P. 1 <br /> Z 2• <br /> d <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional InformationJ90g , <br /> 4 HR E Y1- - '176 (Cid � ® TF1� <br /> AUTH A 0 T— "' VG RETAIN LIETMED SUR CARRIERS <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and a ately 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 intern r&I 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 EPAAck owledgmen Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanti g wwato r(b)(if I am mall q ntityrator)is true. <br /> Generator'/0fferor' intedfTyped N �g on ay Year <br /> 1c1,1 16.International Shipments, <br /> t <br /> t- <br /> Import to U.S. ❑Ex ort m U.S. Port of entry/exit: �'�.• <br /> Transporter signature for ex orts only):' Date leaving U.S.: <br /> W 17.TransporterAcknoyvledgment of Receipt of Materials <br /> i2 �Trap}sp"Ier 1 Printed/Typed N `7 J inure = opn�iry ay Yea r, <br /> a I B td I, ��I <br /> Transporte Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity El T e _ t . ❑Full Rejection <br /> yP ❑Residue ❑PartialRe'ection <br /> Manifest Reference.Number- ,` <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number v <br /> V <br /> �'- <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LM <br /> 1. 6 <br /> 12, 3. :` 4• . <br /> 20.Designated FacilitQwnei,or Operator Certification of receipt,of hazardous materials covered by the manifest except as noted 0Item 18a <br /> Printed/Typed Name Q Signature Mth Day Year <br /> cl— <br /> EPA Form 8700-22 Rev.3-05re 176 <br /> t <br /> ( Previous editions are obsolete: - DESIGNATED FACILITY TO GENERATOR STATE IF REQUIRED <br />