Laserfiche WebLink
`Yle nr%'or type. (Form designed for use on elite (12•pitch) typewriter) ., <br />0 <br />Form Approved, OMB No, 2050.0039 <br />� ` <br />EPA Form 8700.22 (Rev. 3.05) Previous editions are obsolete. `" `' (., DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2, Page 101 <br />3, Emergency Response Phone <br />4. M�ariiffe`s�tTracking Number <br />WASTE MANIFESTlcmwimgw <br />' <br />`� 7 7 <br />e <br />0 0 + I- L E <br />5, Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />3r4tor a7tocktoi <br />�Mt WWNqqtM A. <br />510ck,tar,, CA 9Q01 <br />Generators Phonm <br />6. Transporter 1 Company Name U.S, EPA ID Number <br />CAROM WO <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />f ;�'t1 94cal TrwAnwM.D"410%6Vt' <br />T133 Edith 113M. NE <br />*AAPWV% NM 1107 <br />Facility's Phone: ,5i'05NM9 .5220 <br />one <br />91b. U.S. DOT Descdplion (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />HM <br />and Packing Group (if any)) <br />No, <br />Type <br />Quantity <br />WtNol. <br />'tto;rr-RCRA Hazardow Waste Sow FOAY sxy�ils) <br />1Y <br />i <br />{ <br />Y! '�°' <br />w <br />4. <br />14. Special Handling Instructions and Additional Information <br />pTqw4t fAblibar ,`,�Yos -M 0CV354 <br />�1iFtE'nnf <br />,t>f <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 shipping name, and are classified, packaged, <br />marked and Iabeledfpiacarded, 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 EPAAcknowledgment 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)fif I am a small quantity generator) is true. <br />Generate s Oggmrs Pdplec/Typed,Name. _igna ure r Month ay Year <br />%Or� I LLIA A <br />J <br />H <br />16'rlrllemallonal Shipmeiils "r <br />❑ Import to U.S. ❑ Export from U.S. Port of entrylexll: <br />? <br />Transporter signature for ex rts only): Date leaving U.S.: <br />a <br />17. Transporter Acknowledgment of Receipt of Materials <br />Month <br />Transporter 1 Printedlfyped Name• --- Signature ear <br />IL <br />{per r //1J (,+� Day <br />) <br />t 3' f, l G Y4"p r t i F i f ✓f 'f <br />QTransporter <br />zs; <br />2 Printed/Typed Name lure Mon earl <br />W. Discrepancy <br />18a, Discrepancy Indication Space QuantityPartial Rejection El ❑ Type Residue -. ~❑ J ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />LLC <br />Facilitys Phone: <br />U0 <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Cl <br />1. <br />24 <br />20, Designated Facility Owner or Operator Cer ificatlon of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br />Prinied/IypedName r ,/ 7 Signature /�J Month Day Year <br />A r.� f/' r -, <br />1 „�/ ,--' rte! <br />i� .; <br />