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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) <br /> <br />Form Approved. OMB No. 2050-0039 GENERATOR . . UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAL0002s19835 <br />2. Page 1 of <br />I <br />3. Emergency Response Phone <br />sea- ii2.1-93... <br />4. Manifest Tracking Number <br />010771646 JJK <br />Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />5teekton 7iere emit t: KA% fern gars, ad 13°C) Ger-trudc Ave. <br />/2s2 hi. shAv• Rd. <br /> <br />5tocIrtors 1 CA 95115 5tocit04, OA 95215 <br />Generators Phone: 91a-117-0776 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />c//II Phs-fe Ake i CAROOrt272.773 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Nan ie and Site Address U.S. EPA ID Number <br />grikkLed Agra: <br />(lir/ Sooth Ausfin F?cl• <br />14:usteca,CA 15336, <br />FacilitYs Phoncr,2450e2112a1) 9g2 -12 9g I CM, 0401c100?0 <br />ga. 9b. U.S. DOT Description (includng Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes NM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />A <br /> <br />"1112212 As6cs-fOs q PaIll. RR 79 BA 4:0 Nr <br />. 1 5 1 <br />1 I i i <br /> <br /> <br />I <br />14. Special Handling Instructions and Additional Information <br />rRcy7f--/71 <br />4it 4 0 0- <br />Fi?.,C:14 - g26 4/2/2$957 P_Ii.r, - 451. OM r‘r 26395 _ - goo4.2 <br />15. GENERATOR'SfOFFEROR'S CEFMFICATION: I hereby declare that the contents of this consignment are fully and accurately descri above by the proper shipping name, arid 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 lam 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) (if I am a small quantity generator) is true. <br />Generator's/Off )Printed/T ame Signature Month Day Year , •r <br />-,-- 707 I 6 - / I 2 I 12.122. <br />_i r- <br />g <br />16. International Shipments Import to U.S. Export from U.S. Port of entry/exit. <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER' _ <br />17. Transporter Acknowledgment of Receipt of Materials . <br />i <br />Transporter 1 Printed/Typed Name Signatu 1 Month Day Year <br />-a-ney._FrIcJIG4 Ary.,.....„... <br />111:7 i V i is 1S2. <br />Transporter 2 Printeci iyped Name Signe i Month Day Year <br />I I I I 4-- DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection LI Full Rejection <br />Manifest Reference Number <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day ,i Year <br />I I <br />19. Haz ous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. 4. <br />20. Designated • ity Ovate or Ope tor C • cation of r 'plot hazardous materials covered by the manifest except as ncted • Item 18a <br />Printed/Typed am rs <br />6/ <br />f itha, .-.) _______ 1 Signature <br />.....- <br />l2,orit,h <br />1 <br />Day <br /> 1 17/I l' <br />EPA Form 8700-22 (Rev. 3-05) Previous edition are obsölete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)