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CC) � �� / ) �� 12 `� <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) F6m,Approved.OMB No.2050 0039 <br /> UNIFORM RIAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.ManifestTracldng Number <br /> WASTE tNANIFEST Y, i A 0 3 Y 5 GGi T� L'01 009897344 JJ K <br /> 5.Generator's Name and Malfutg Address . Generators Site-Address(if dairent than marling address) <br /> AFFY !USE#222 <br /> 500 E--KETTL-W-AN FID. <br /> GeneraloDrs Phone: � ' ?y(JQ 95240 , "d 1,6i <br /> s0-5 3ic <br /> 6.Tr(alnsport(erF�I Company <br /> /Name 7 { r�j�i { U.S.EPAIDNumber <br /> ASBU t�Y EN YM-NMEN AL V� � tom.;L s - 7 7 4 ti t+ <br /> �`Ii i�.r <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designaitted Facility Name and <br /> �Site Address U.S.EPA ID Number <br /> SIEMENS IN`�FIF�F ,INC DEPARTMENT <br /> 5375 SOUTH KYLE A VENUE <br /> LOS ANGE ESCA Q00Ij$ t"A0197w376993 <br /> Fad s Phone: <br /> (d2;:)1' _`�-:L501f <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.UnR 13.Waste Codes <br /> HM and PaddrtgGroup('rFany�)- <br /> No. Type Quantity WtNol. <br /> HjAZAR 'f�iUti.WA :7--.SOtUD (OIL':SOL; —F 0/ � l' /} T Stoll <br /> Z 2 i <br /> 3. r t <br /> 1 <br /> i <br /> 4. <br /> Y <br /> ( <br /> r <br /> 14.Special dandling Instructions and Additional Information <br /> r zc itw#SR_�-_:AP 6T-9S OILY <br /> ,3�fmt15. GENERATOR'SIOFFERDR'S CERTIFlCATION:I hereby declare that the contents of this dr44d!�are till and accurately described above by the proper shipping name,and are dessified,padmged, <br /> marked and labelediptacarded.and are in all respects in proper condition kir transport according to appl'rcab',a mtemational and national govemmentai regulations.9 export shipment and 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmotvtedgmerd of Consent <br /> I Certify that the waste minimization statement idelrtified in 40 CFR 262.PT(a)(ti I am a large quantity generator)or(b)(il I am a smal quantity generator?is true. <br /> Qpneira#7s P ntad(fyped Name <br /> TJ <br /> J 16.International Shipmentsrt from U,g, Port a entryle <br /> ❑Import to U.S. <br /> Transporter signature(for exports onl): leavi S.: <br /> W 17.TransporlarAclmowtadgmentOfReceipt ofMatsdats <br /> Trans r 1 Prime Name ��/ Sign Year <br /> aI/ <br /> Z Tra iter tint ad MoMfi D Year <br /> A <br /> 18.Discrepancy <br /> 1 Be.Dsaepaney Indication Space ❑ Quantity Type ❑Residue ❑Partial R%wtion ❑Fug Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> Faalit/sPhone: tAorrlh Day Year <br /> w 18c.Signature of Altemate Feality(or Generator) <br /> Q <br /> yz disposal, recycling Sys e <br /> 19.Hazardous pod Management Method Codes(e.,codes for hazardous vraste treatment,dl and t ms) 4. <br /> Q 1 2- <br /> 20. <br /> 20.Designated Faclllty Owne or e .Certification of rete hazardous giffarials coverer by the manifest except as stied in Its Year <br /> Day <br /> dnW/Typed Name Signature MotlUt <br /> 163 V2EPA Form 8700-22(Rev.3-0 ) Previous editions amwsolete. DESIGNATE FACILiTYTo D INATION STATE(IF REQt11RLD) <br />