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i <br /> f. r'.t 0, ;r(i l"? <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter)°) -170tit0195r MY? (,f-,}"PW 0 <br /> Form Approved.OMB No.2050.0039 <br /> 11NIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number, <br /> WASTE MANIFEST F L E <br /> 5.Generator's Nares apd Mailing Address General or's Sile Address(it different than mailing address) <br /> ':trrf`I!Ftlli CA 9fl'203 <br /> Generator's Phone;' <br /> 209194'11-036)0 <br /> 6. ransporter 1 ompany ame U.S.EPA ID Number <br /> li`'r1t11(.ax)Fr!: i 9tYPi+lfflHNhdiAI�iNC•/S!•#.`S,�ilf7 .. `_f _i �h �; �i ty (S <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 /> ,r1!;�!1ttb:fl Pill .N ti�1'�•_/ <br /> Facilites Phone: ('S.t •.�1 ' <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WI.NoI. <br /> 1.1)43wM4,tit)11Wl 1`01,11T 1)N114fa r`-ORfitOSIYk:I IQ(lI_'),11 <br /> o ,.!°yt�h'(X.;.F;Er)(tis ttl() Gl111(rAml( A('it')),f;•p'(f•11 t> <br /> a� <br /> w <br /> Z 2- <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handlipg)nsWcUonsrand Additional Information <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,and are classified,packaged, 1 <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. q <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generato s/ eroesPrinted/Typed Name Signature Month Day ear <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> �2 Transporter i Printed/Typed Name Signature Month ay ear <br /> CL <br /> rn <br /> z� Transporter 2 Printed/ryped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> LL <br /> Facilitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ireahnent,disposal,and recycling systems) <br /> 0 1. .. , 2. 3. 4. <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 /> 1 <br /> EPA Form 8700422(Rev.6.05) Rrevious,edifions are obsolete;p, I%I and will aecelit tltu v/ai te the genetat!!T i!.ihippiul! GENERATOR'S INITIAL COPY <br />