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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Ge erato I 2.Page 1 of 3.Emergency Respc` 4 Ma <br /> If Tracking Number <br /> UNIFORM HAZARDOUS ?a't b�nt�i 8 2.4 5 6�9 8? 3 3& 1 11! <br /> WASTE MANIFEST b'.L tJtJ f� <br /> 5.Genej~EUEkW#gLq&dress Generators Site Address(if different than mailing address) <br /> 500 E. KETTLEMAN RD <br /> LCI D i CA 95240 <br /> 209 339.09W <br /> Generator's Phone: <br /> 6.Trans bWIffl .MNMENTAL SERVICES U.S. PJ�It�I r nb�r6 ( 7 Q 3 U <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DesiggJeCF:V1 �� i U.S.EPA ID Number <br /> V5375 SOUTH BOYLE AVENUE <br /> LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: <br /> (.'+2;027 7-15W <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contame's 1t Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Tyke Quantity Wt Vnl <br /> 1, I G, ,tVILYt I-ILI ) <br /> O <br /> z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> --CmrMUCLAGY QONTAX;T:WiLmI HEL I.-800-42493W WOES TERMINAL:(XhES C-S IYAEkC,#�i6i. 1;1 r P tor iLt#:9131 <br /> AP167298-1 OILY PAPER FILTERS *P500-00050788 k APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> o <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)('if I am a large quantity generator)or(b)(NI am a small quantity generator)is true. <br /> Generator's! eroes Printed/Ty ame Signature Month Day Year <br /> J 16.IntemeItional Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> Transporter 1 PrintedfTyped Name Signature -7 '----3 Month Day Year <br /> AtO _- / L /E <br /> a l4wP�llrC� C=j�WGv' �.,g <br /> QTransporter 2 Printedrfyped Name Signature Month Day Year <br /> F <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 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 /> Facility's Phone: Month Day Year <br /> 18c.Signature of Alternate Facility(or Generator) <br /> H <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. 3. 4. <br /> L <br /> 20.Designated Fa6lij Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item I&a <br /> Si nature Day Year <br /> Printed/Typed Name � 9 � G/?� (,1, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESI TED FACILITY TO GENERATOR <br />