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Please print or type - <br />UNIFORM HAZARDOUS 1 Generator ID Number <br />WASTE MANIFEST I '"%'-tM,#l,��sfpS.►I-I <br />5- Generators Name and Mailing Address <br />2- Page 1 of 3- Emergency Response Phone <br />I 1 1100 mt1:11-4t1tR1 <br />I %A;K I kA4 I"K(Jtsk L i-ta•t <br />4114 fd WI1.f,:t)Y, RE) <br />I if.:Ih i <br />'4U;;r- I tt'� C u - i iX, <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />f%1E:ttiS;aAht lA"►I.L1-.Y Y1fA81E lJtl.. 11JC... <br />7. Transporter 2 Company Name <br />! EFTIC)YGII F SVIL- iIALTY WASH. ",3t)LU'110IN16, INC <br />8 Designetad Facility Name and Site Address <br />0irM-kAl'K:hl<:tr.AJRY.Ni1VA, Lf, l: <br />1 II366'11YH k: ttLx"K <br />RAN(> v"a <br />Facillty's Phone:Fl1(-3514AjW <br />9a. 9b. U -S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />O 1' R0I IRI1)R1 1AIXR'T'TT- PAIM RF1 ATFf't KAATFFTIAI 3 14',11 <br />w <br />Z �. <br />LU <br />(7 <br />3. <br />special Mana{mg InSnCh0r35 andAddilional Iriforrna6m <br />I'ItOHI I=#Idistbb34•iKi i4AI04I VVASIL. C)Il- t4J1Wit [) ;-N�� i1IS <br />bIwFRG17W,'Y C'XWrAC;1; MIKF <br />Form Approved. OMB No. 2050-0039 <br />Track€nNumber <br />30~954 JJK <br />than mailing <br />U -S. EPA ID Number <br />CAFt000272317P <br />U.S. EPA ID Number <br />A(14WXlp 1 i U924 <br />U.S. EPA ID Number <br />f Att R,flliR.f jxj <br />10. Conlainers 11, Total 12. Unil <br />Na. Type C1uently WI.1VoL t3- Waste Codes <br />Ilf1IJ i �I, 3 1 214 <br />15, GENERATOR'S/OFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the proper shrpping 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 Acknowieagment of Consent. t i <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifl am a small quanRy g!narajoTis hue. <br />Generat&VCfferor's Frmled7yped Name Slonature M <br />16. International Shlpmenls <br />f— ❑ Import to U.S- <br />Tran sporter <br />.S- <br />Transporter signa lure tfor exports only): <br />W 17, Transporter Acknowledgment of Receipt of Materials <br />W <br />I tangpo 1 PrintedlT i Name <br />❑ Export from U.S. <br />R">rt of entr�'exd <br />Date leaving U.S.: <br />18 01screpanay <br />18a. Discrepancy Indication Space ❑ Quantity <br />❑ Type F1 Residue <br />Manifos[ <br />18b. Alternate Facility (or Generator) Reference <br />U <br />LL Faclilty's Phone: <br />W 18c. Srgnalure. of Alternate Facllrty (or Gemralor) <br />a <br />2 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste req cll <br />treatment, disposal, and <br />W 1 <br />P Y ng systems] <br />[5 • 2• 3, <br />20. Designated Facility Owner or Operator: Certification of recelpt of hazardous rnatenals covered by the manifest except as nded in Item <br />PnntedlTyped Now Signature <br />EPA Form 8700-22 (Rev. 12-17) Prevlous editions are 9bbsolete. <br />Number: <br />❑ Partial Rejection <br />U.S. EPA ID <br />ant <br />Month Day Year <br />Month Day Year <br />❑ Full ReJectlon <br />•Notice: State of California requires J <br />generator to photocopy and mail to <br />;DTSC with 30 days: <br />P.Q Bax 400 <br />Sacramento, CA 95812-0400 <br />GENERATOR'S INITIAL <br />Year <br />