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Form Approved. OMB No. 2050-0039 NTI I 4 GENERATOR UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />I. Generator ID Number <br />CA COO -g,0 7-7 et3 <br /> <br />z <br />2 Page 1 of 3 Emergency Response Phone <br />goo ,z(-ill3.C. <br />4. Manifest Tracking Number <br />021913507 JJK <br />Generator's Name and Mailing Address Generators Site Address ([? different than ma1Ing address' <br />(.4 ex.7\14,- en te, p r 1 c, e ‘ r‘ c . evvi-eitprigre.s1 - frivc, <br />ILI g 0 -7 Fro A +3 ed- R 4 27 •-74.02 / ..-121 • ci y 7s- <br />oitk A4-14, NE 4,g 1 3g Tr4 CA <br />Generator's Phone. I ciAd ' <br />Transporter 1 Company Name U S. EPA ID Number <br />pr,-i--eAv J P. o Am evot-a-( stry ices 1 cisti_Dos38(.61-1A-1 <br />1. Transporter 2 Company Name U.S. EPA Ii) Sumer <br />I <br />8. Designated rackty Name and Site Address , U.S. EPA ID Number <br />CroSby 6 otre/foil <br />U30 w. 1144.• 5+ 1.0 1 06A-cil C4 t.°1-1.) 0 2 6( - / el , a I et <br />Facility's Phone: 'e 00 12-1 (212.9 I <br />ga. 95. U.S. DOT Description (inciudkig Proper Shipping Nerne, Hazard Class, ID Number, 10. Coital, ems it. Total 12. Unit 13. Waste Codes <br />NIA and Pecking Group (if any)) ./4* N. , . Type Quantity WI/Vol. <br />I „I A- Fig r 4,s, -11-e- co 11 0 pm -c_40, p 352 (v-0 AI IQ CR z ,A t,,ek s <br />de b ri es c(c,, p s e- <br />2. <br /> <br />ii, ‘.• <br />3. <br />, <br />Special Handling Instrucblions and Addittiona: information <br />(A 5 e. pro g er pp <br />3v to 41- 08 - Zo — 00 4 ° I ,.., : ., ) Se <br />GENERATORS/OFFERORS CERTIFICATION: therabOeclare that the contents of this consignrgent are fully end accurately described above by the proper shtpping name, a are classified, packaged, <br />marked and labeled/placarded, and are In all respects In Otter condition for transport according to applicable international and national governmental regulations. It export shipment and I am the Primary <br />Exporter, [certify that the contents 01 this consignment tonfo6m to the terms fthe enached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40,C 'CR 262.2 a) (if I am a large quanbty generator) or (b) (III ass a smal quantity generator) Is bee <br />Generators/Offere4 PcintedITyped Na646r Signature Month Day_ Year <br />On 6eltdrof .J.rn.el *Ice 5 <br />Po ol entry/e CI Export Pot xiL international Shipments LII tram U.S <br />ImPa Transporter signature (for exports onl <br />Import <br />t° U .S. Date leavng U.S.: TRANSPORTER I Transporter Acknowledgment of Receipt at Materials <br />Transportra. 1 Printed/Typed Name Signature Month Day Year <br />AS /4 k' /WI riAeg 1 t'Vet-O(OtP'"""---- <br />I <br />_ <br />Transporter 2 Printed/Typed Name Signatue Month Day Year <br />I I I <br />i <br />D <br />a u. <br />uj <br />i- 42 Z <br />S2 <br />LU ,.. <br />Discrepancy <br />Ma. Discrepancy Indication Space M Lliype • <br />Residue II <br />Manifest Reference Number: <br />PartiOI Rejection 1:=1 Full Rejection <br />185. Alternate Faulty (ot Generator) U.S. EPA ID Number <br />Facility's Phone: <br />CI 18c. Signature of Alternate Facility (or Generator) Month Day <br />Hazardous Waste Report Management Method Castes (i.a., codes for hazardous waste treatment, disposal and recycling systems) <br />1. •N 2. 3 <br />Designated Facaity Owner or at t. Certification of receip f haze . us materials covered by the ranifest except asncted in Item 1 a I <br />'Printed/Typed Nil <br />tittALV <br /> <br />• Si Sir.)..1 Day I A, Signature <br />1 0 I 2-41 <br />rs,61, k, n -r r r, c A pit ITV Trr croA 14 a_11/1AlttlrFQT AVRTF IV <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.