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Please 11 ' tr 1 pa. Form Al OMB No.2050-0039 <br /> 1,Generelor Ill Number ' A Page 1 of 3 Emergency Response phone 4.Manifest TrAchl Number �[ <br /> UNMF4fiM HAZARDOUS 4b'i !a _ ' , ) �"}� � �)�,�-`- 02 JJK <br /> WASTE MANIFEST 0 <br /> 5 Generator's Name and Mating Address Generalor's Sile Address(if different than mailing address) <br /> 11R `i'l. t,A WMIX) <br /> Gereralar's Phondl:tf U S,EPA fD Numher <br /> 5,Trallsporter 1 Company Name <br /> •'lfvtt'I{11,:Af�l 1841 1 i•V WA! I I +•H Ir`!r 1?JA <br /> i 7 ransporter 2 Company Name <br /> U S.EPA ID Number <br /> .•,� '++ i1'1r1t 1! lt k-' VI <br /> 8.Designated Facility Name and Sita Address <br /> U.S.EPA ID Numhw <br /> i IM I I(Al 1 14 1 A. 1t 11 r <br /> Facllity's Phone`.`•'( <br /> 8a 8b.U.S.DOT Deso6 ion(including Proper Shipping Name,Hazard Class,ID Number, 10.Contatnors 11.Total 12.Unit 13.Waste Codes <br /> HM and Peeking Group{;rang)) No. Type Quentfy WI.+VaI. <br /> 1 1ti1[1f�1 li 11-1i RIN-N f�.Ill 11 ';+it 'i r 111 ii: 51.111 I`,, I'Al'F'ft i Al71 rA� <br /> o <br /> W ' <br /> 2 2. <br /> W <br /> C7 <br /> 3. <br /> I <br /> 4. <br /> 14,Special Handling InSbucticros and Additional Information <br /> ►?APEER11-{Ill Lil 171 r � <br /> r:F,ilkf{:7+r f�C1' t:Ot1i fnC? ,IA;M1� ll•1�ICyy <br /> 15 GENERATOR'SICFFEROR'5 Ci_RTIFICATiON- I hereby declare that the contents of this consignment are lolly and accurately described above In the proper shipping name,and are classified,packaged, <br /> marked and labeledlplarArdad,and are in all respects in proper condition for transport according to applicable intemalionaland national govemmbhtal regulations,If expokshlpmant and I am the Primary <br /> Exporter,Ice*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 1262.271(if I am a large quantity generator)or(b)(ill am a small quantity generalor)is true. <br /> Generator'V01feror's PrinledfTyped Name Sjgnature i -pay 'del <br /> Tom! t � 4 <br /> �cel tit r xL r,f', �' <br /> r <br /> 16.Inlemational Shipments <br /> Import to U.S. ❑Export kum'1f.9. Port of antrylexit: <br /> Transporter signature(for exports only); pate leaving U.S.: <br /> M 17,Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 P dlTyped Name f 9ignatu e,._ , Month Day Year <br /> /�y�F'' i'% �f�}:•r' 7';r^!" ,,,[f'i�•-'i' .. ~}fry: - '1 <br /> a Transpq er2Printe (Typed amen Signalure Month Day Year <br /> 18.discrepancy <br /> 18s,Discrepancy Indication Space ❑ Quandly ❑Type ❑ 1 <br /> ❑Residua Penial Rejection full Rejection <br /> Manifest Reference Number <br /> 18h.Alternate Facility for Generator) U S.EPA ID Number <br /> C] <br /> Facility's Phone: <br /> w 18a Signature of Ahemate Faulty(or Generator) Month pay Year <br /> 2 <br /> 0 19 Hail Jous Waste Report Management Method Codes(i.e.,codes for nazardWS waste treatment,disposal,and recycling systems) <br /> to <br /> LU 2 Notice: State of California requires <br /> " t generator to photocopy and mail to <br /> 20.Designated Facilily Owner or Operator.Certificalion of receipt of hazardous materials covered by the manifest except as mAed in Item 18a OTSC with 30 days; <br /> Prinledfryped Name Signature P-0 Box 400 <br /> Sacramento, CA 55$12-0400 <br /> EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> J <br />