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Please print or type.(Form designed for;use on elite(12-pitch)typewriter.) . FormApproved.OMB No.ZG50-0039 <br /> UNIFORM i1ATAR6 0US 1.Generator II]Number: 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trot Humber <br /> .3.- 018681602 JJK <br /> I WASTE MANIFEST -. <br /> 111 5.Generata>s Name and Mailing Address r Generatces SitaAddresa.(if different than mailing address) <br /> 14ftaa r t+t JTV0ID t+ti Lofhrop-CAf 96330 Ulq*,;Bsnt�uta <br /> Generatn>'s Phone' : ;G =7m.�9'r X,n#}a � [€Ffhr.81rPelfa!t xTxa hS� <br /> 6.Transporter 1 Compsny Name -a U.S.EPA 16 Nudiber <br /> 7.Transporter 2 Company Name U.S.EPA iD Number <br /> 8.Designated Facility Name and Site Address'.- :: ]V@IT011,Inc U.S.EPA ID Number <br /> _ is�1B�8T�.�ii7efCdjY34AwGS6Y�(;'�13b'.Y"�i> F'�E.i cam{ .• <br /> i.t "h.CA 9U?W USA <br /> ::' �`^QF,;�.�:,��5? r n a',f;s '-':^r,g '1{itr ---:3 Jaiti :f--r'% s:.-s. + :.v�.9• ,�!:nr,;n�aria.- :-.M=' =,a(;c;ay c.-q:;:t;1-cif:. . <br /> Fadi s Phone ti <br /> got 9b.U.S.DOT Description tinduding Proper Shipping Naha,HaiOtC]ass,ID Number, S0.Containers 11.Total 12:unit 13.Waste Codes <br /> HM and Packing Group[rf any)) No- Type Quantity WtNol- <br /> lx 2. enrr 3+r1an y:nc' *;. <br /> c <br /> 3. <br /> 4. I <br /> 1 <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION:I hereby dadare that the contents of this consignment are fully aW accurately das(Abed ahove,by the proparshipping name,and are dass[W,packaged, <br /> marked and tabeledlptacarded,and are in all respects M proper oondtion for transport according to applicable international and national goverrimentat regulations.If export shipment and I am the Primary <br /> Exporter,I certify Shat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent' <br /> V certify that the waste minimization statement identified in 44 CFR 262.27(a)(H l am a large Quantity generator)or(b)(if I am a small gga*,Rnnamtor)Is true. <br /> GeneratofsrOffaroes Pdntedliyped Narne Signature Month Day Year <br /> 16.International Shipments <br /> F-- ❑Import to U.S. ort from 11-S. Part of en fexiL <br /> ❑Exp try <br /> Transporter signature(for exports only): Date leaving U.S.; <br /> 17.TransporterAckmWedgment of Rampt of Materials <br /> LU <br /> �j Transporter 3 Prinledffyped NW Signature Monih Day Year <br /> Mt ranspdrter2 Printed)Typed Nene SigmahuB z Month Day Year <br /> rr <br /> F-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spam ❑ Quantity ❑Type ❑Residue 0 Partial ReJectien ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> LL Facility's Phona' <br /> 18e.Signature.of Alternate Fadfrty(or Generator) Month Day Year <br /> Q <br /> Hazardous Waste Report Management Method Codes(i.e.,codes for haxardaus waste treatment,&sposaf,and recycling systems) <br /> 2. 3. 14- <br /> 20. <br /> Designated Fgcilfly Owner or Operator:CertiPooation of raeaiptof"rdous materials covered by the manifest except as noted in Item 18a <br /> PdnledlTyped f i Signature Month Day Yaar <br /> EPA form 8700-22(Rev.3a) Previous editions are obsolete. TRANSPORT F-R'S COPY <br /> S_ <br />