Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma <br /> nifest Tracking Number �/ <br /> WASTE MANIFEST A L 0 00 .; 3 u r' � � i 800.424-930f-d' 8 3 6 9 4 8 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> i 1 1 L.0 tPA,.j10146 <br /> EL t::EN�z;=�:_ l-t%�_.L.'>' A R L 0 W E� I'�IL.�>}T'4 : 17 <br /> P-0' 80 01 a6 KN,'I,J�',Vy t,"E TN. _379 'La {��UCr 11+ .E�t��t�i�i�F1 RE L01). 'A 95242 . <br /> Generator's Phone: <br /> 8t''. 588 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> t. .�'"Fi i. . J_.ti.t' ;....�t:< r .'-..,t r.: - n.'.ii.i P7✓(J.::1. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Farrciiility Name and Site Address U.S.EPA ID Number <br /> .-'Viii IndN I_ 8 E.R C.t,Itl' <br /> 2000 NORY14 ALAMEDA ST. COMPTUN- :A. 90212--2799 <br /> Facility's Phone: j' `f <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 <br /> ¢g fPacking Group(9 any)) p y� { N.O.S. No. Type Quantity WtN01. p g{ <br /> Q 1 'U14 19r�3, 9�.A S T E Ft.. MMA 8LE 1 .iQlJf0, p '�f�t✓ 1134, 1 <br /> W <br /> W 2. TMIS WASf E STREAM HA BEEN 1,18A.,8v <br /> FOR RECYCLING/TREATMENTS AT THE <br /> KEROOON FACILITY IN COMPTON, <br /> 3' CALIFORNIA.THIS FACIL1171Y HAS THE NECESSARY <br /> PERMITS TO YOUR�NASTt STREAM AS .... <br /> 4. QUAtIFIV. ', 1 r N Ir. R IS <br /> l <br /> i <br /> Z <br /> 14.Special Handling Instructions and Additional Information <br /> HE SP I RA <br /> p _ 'IPPROVAL 0- AP' <br /> . ?4 ROfisI7 EtiCIrV_;>}CC Y CTJN,.AC+- <br /> FIFMrREC; 800-424- 0 <br /> 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,arca 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 Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GTtor's/Offeroi's Printe IfTyped Name Siiggnna`ture - �L -- y Month Day Year <br /> 3 <br /> 16.International Shipments <br /> z ❑Importto d( ❑Export from U.S. Port of entry!exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransport Printed ssped Name Signature ,` Month Day Year„ <br /> IL <br /> ZQ Transporter 2 Printed/Typed Name Signatures Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space a <br /> Quantity ❑Type r f El Residue r� El Partial Rejection Full Rejection <br /> F?ecOnciledquantity with <br /> `t t n. <br /> ( <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q ' <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> Mug <br /> 20.Designated Facility Owner or Operator.Cefification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed!Typed Na e ` Signature Month Day_.. Year <br /> 1 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />