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J� <br /> o t Generator ID Number <br /> 2.Page 1 of 3.Emergency Forth Approved.OMB No.2050.0039 <br /> NIFEsT s 1�t143t1 9 cY Response Phone 4.Manfleat Tracking Number <br /> sTE MANIFEST ' <br /> _w-roes Name and Mailing Addre s!�a;Mt ,AW023581255 JJ K� ��`�'� <br /> I�A E MAIN S7 Generators Site Address(if different than mailing address) <br /> � <br /> f(A;K 1 Upi.(.A %2ot> <br /> Generators Phone: b,:moi L-bi <br /> 6.Transporter 1 Company Name <br /> N+NENJUANMkLi_I-y WAS IF OIL,ItC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number GAfftXJ1l <br /> _tilt Yi;Lt SI _(;iALIY WAS IEWILUIKhgs WC <br /> U.S.EPA ID Number <br /> 8.Designated Fadlity Name and Site Address' MVS(1U01 1 OI124 <br /> IIsi I:tNIUKY�IyiftuNMf_NfA1 <br /> tlkY3 iVtyy��,1JPt.F.A$1 �isrY11 OF PJr.1lAl;q,t.!_e. U.S.EPA ID Number <br /> i'CRNLL-'f,tN asaaa PdVrlUfit1f1A5'i't�, <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Padang Group(if any)) 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> FJj-,/,,-4 No. Type Quantity WI, <br /> -n 1 N'yt 6.t:tAtAF.T f !f[H H11 hl t).� 4 pf:111 r U(N?: :342 <br /> r►{Rl�DRt?M•s <br /> W <br /> W 2. <br /> f.7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instrw�ons and Additional Information <br /> I FtilhiLi✓# 1/t33i:id-t _"11'41l4dt;tiLU1X-iF: i ittillt ►r i <br /> kAtitNt3EJVt:Y t..'uNTAt;i_ NWliY <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION:I 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 respects 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 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)(ill am a small quantity generator)is true. <br /> Generaloes/Offeror's Printedfryped Name Signature <br /> Month Day Year <br /> I6.Intemational Shipments <br /> I-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> w 11.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedfryped Name Signature <br /> O - Month Day Year <br /> a <br /> Z Transporter 2 PrintedlTyped Name <br /> Signature <br /> r Month Day Year <br /> 18PAItemate <br /> Discrepancy <br /> y Indication Space <br /> ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> F}-- adlity(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> Facilitys Phone: <br /> UJ 18c.Signature of Altemate Fadlity(or Generator) <br /> a <br /> Z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous w7treatment, osal,and recycling systems) <br /> w1 <br /> 2. <br /> 3. Notice:State of California requires <br /> 20.Designated Facility Owner or Operator:Certifipfion of receipt of hazardous materiyemanifest except as nosed in Item 18a generator to photocopy and mail to <br /> PnntediTypedName DTSC with 30 days: <br /> Signature <br /> P.0 Box 400 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> Sacramento, CA 95812-0400 <br /> UhNEKATOR'S INITIAL COPY <br />