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PIC so print or typo, <br /> I UNIFORM HAZARDOUS 1 Gonorntar ID Numbar Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST 2.Pai o tIfi. Roaponso Phone 4.Manifest Trockfng Number <br /> l:Alttu :l.Iu1lU + -_sm�tfsurl, JJK <br /> 5 Generators Name and Mmling Address <br /> Gonoralore SIIoAddress(if dillumnl Ihnn molling address) <br /> ;iltl7l<I bIU1'F(ioUMAI<I <br /> 1()W 1 WNtk fel)y11 A <br /> Gunorators Phon LOUT•CA W)24(I <br /> G Tmnsperter 1 Company Namo ' <br /> US EPA ID Number <br /> /IMl:kll./W v ALI.L-Y WA,%ll.ijll,INC <br /> 7 Tmnsporlar2CompanyNamo LA111R1f.17.l7:itY1 <br /> US EPA ID Numbor <br /> tirr_nIUY(AL SO'ECIALI Y WA:iIL Z-,0LU11UN:h.INI_ Nil Iffrl`24 <br /> 6 DosignaTed FucillfyNamo and SIIoAddross <br /> U.S.EPA ID Number <br /> liL•N-ILMK:IiV CVHU(tVq,11 t; <br /> I IlI55 WHITk KOCK KU r:Al)QW)AA41AA <br /> f1At4CFl0 CORIkSV,&. I"A 10,1-12 <br /> Facility's Phone}+11r 3g I{� <br /> ga, 9b.U.S.DDT Des ion(including Proper Sopping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(d any)) 11.Total 12.Um! 13.Waste Codes <br /> 1 No. Typo Ovanury WlNol, <br /> Rn INY"" WAtiT'FPFTROIF11MI.li:T111Art rJr)!, I�„'i <br /> L1C1U 1 Ula l it 3;1 I <br /> 9A.C1r1I1NF h(�GFI <br /> z 2 <br /> w <br /> C7 <br /> 3 <br /> 4 <br /> 14 Special Handling Instructions and Additional Information <br /> I'fZOF1LJ=# I/U8284-U9i t:!r5,WAl LN FH60 116 <br /> i-MFHGFWY CONTACT 5AM <br /> 15 GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are ruby and accurately described 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 EPAAcknowledgmeni 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)(ill am a small quantity generator)Is true. <br /> Generatorsl0fferors Printed/Typed Name Signature <br /> Month Day YeLj <br /> ar <br /> w i6.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entiylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> -X17.TranspoderAcknoWedgment of Recuipt of Materials <br /> W Transporter, 1 PrinlCL Cb �Aecri <br /> yped Name Signature <br /> 1 Month Cn <br /> 7Yea,Transporlor 2 PrinteddfTyped Name �J <br /> aaQ SignaWro Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Re)ec8on ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aflernalo Facibly(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facilily's Phone: l <br /> w 180.Signature ofAllemale Facility(or Generator) Menlh Day Year J1 <br /> Z <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) — <br /> 0 1. z. 3 Notice. State of California requires <br /> generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operator:Certificalion of receipt of hazardous materials covered by the manifest except as nded in Item 18a DTSC with 30 days: <br /> Punted/Typed Name Signature <br /> P.0 Box 400 <br /> Sacramento, CA 95812-0400 <br /> EPA Form 8700-22(Rev. 12-17) Previous edilions are obsolete. btNtRATOR'S INITIAL COPS' <br />