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0T;f. 0-1.0--89. 0768 <br /> Please print or type.(Form designed for use on el to(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response PhoneManifest Tracking Number <br /> WASTE MANIFEST G A L o 00 1 h 3,�:.�:�.. . 19,00-q2q- J-3007-006068324 JJK <br /> 5.Generator's Name and Mailing Address Generator's Sita Address(if different than mailing address) <br /> JARS; O SERVICE,. <br /> III N aJ r-64,,,j ... 04y <br /> '%to 4+&" C� 462 o7 <br /> Generators Phone: 010 - +JL <br /> 6.Transporter 1 Company Name ;. U.S.EPA ID Number <br /> :FR ENVIRONMENTAL SERVICES INC. Phone#.801}559~3774.:. CAR0001.71017c <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and . U S EPA�IDr Number <br /> ,urm�ber <br /> 1e � es . I ;. <br /> M,a�\ir44 1 ROAD20EI r1 <br /> 4C;rAD9A':824Y 4t'6r8u74 kE:`; <br /> DA At,CA 95916, S. <br /> '•-_�::.�510-7.95-0�100t�. . <br /> Facili s Phone: <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 Packing Group(it any)) No. Type Ouantity Wtivol. <br /> 1•= • . - u . N.. ., •b't�S=T Ax„h:.'r',lL.r�).�t: 'i l" •:7-...i:i:. ��i: ':�,I�.'..-:.7; .... 'S•, .i i�- :�a <br /> d' <br /> 00 <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. �1 <br /> L \ <br /> 14.Soecial andiipp lhsW RandAddi;on on PE <br /> YY44�H [[�O DDee 44((11 RR VV33af <br /> SIM). <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATIO : 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all r pects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of th s co'r nment conform to the terms of the attached EPAAcknowledgment of Go sent. <br /> I certify that the waste minimization statement i entified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b r am a small quantity generator)is true. <br /> Geneor Off roesPrin d me Signature Month Day Year <br /> + I rtq O <br /> 16.1 era nal Shipments. <br /> 1- ❑Import to I JI.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> � 17.Transporter Acknowledgment of Receipt of Materi Is <br /> L <br /> i� Transporter 1 PdntedrTyped Name Signature - Month Day Year <br /> 0r d <br /> CO Transporter 2PrntedrTyped Name Signature Month Day Year <br /> 4 <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ ❑ <br /> ❑ Quant11 Type El Residue Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPAID Number <br /> J_ <br /> V <br /> LL Facilitys Phone: <br /> w 18c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ <br /> C31 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except asfdgd in Item 18a <br /> PrintedrTyped Name Signature 4 Month Day Year <br /> A r? (-56 IA , q <br /> EPA Form 8700-22(Rev.3-05) Previous editions at a obsolete. DE T 2!L- T DESTBNATION STATE(IF REQUIRED) <br /> 10605.2064 <br />