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Please Drint or tvDe. Form Approved. OMB No. 2050-0039 41 GENERATOR > I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator In <br />C <br />Number <br />COO g 17 (-(6Zz-( <br />2 Page 1 of 3. Em er ency Response Phone <br />&-.5 G - ?f)90 <br />4. Manifest Tracking Number <br />0 2 2 2 2 8 3 7 8 JJK <br />Generitor's Name and Mailii g Address Generators Site Address (if different than mailing address) <br />kik-,k C 7c Q aeAd,Aj Pfr <br /> <br />Up - gor-004-awn, .. .1 /i <br />37 4/C fq -I IN - 17-J -7-2.ig ". (1 ki <br /> <br />Generator's Phone: i-iil ?L( 3 - 9C 71 I 9o1 <br />Transporter 1 Company Name U.S. EPA ID Number <br />A n,e4A) 5e r v li e•,5 i CA OPP -737063 <br />Transporter 2 Company Name U.S. EPA ID Number <br />VII' V.Ly '`Z-Al <br /> <br />j( j- 0 I L L.LC I (1_,1A-L-6(30 3 85 c-i3 <br />Designated Facility Name and Site Address U.S. EPA ID Number C_,cog by <br />1(clol tA) 1? i'lx, 5 4-re-e-71- LO Ser,..Ac-, f , 940 C A D OZIV 90 , <br />Facility's Phone:--5-efy?__ <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Cl so 10. Containers 11. Total 12. Unit 13. Waste Codes <br />Hm and Packing Group (if any)) No. Type Quantity Wt./Vol. <br />1. <br />/1) OW te, 024-41 Z- 0 r2 00g teielic),,e, YO/1 j <br />I._ 50( / 50 i 1-) <br />00/ PAA Z-50 <br />5-Z- <br />3. <br />. <br />14. Special Handling Ippc luir rid Additional Informajion ti..V4k.r 10 rep, Pit <br />1 Y57.5" 7 762116, <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, art 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 Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if lam a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signature Month Day Year <br />- at Ocii, a] r of &oetevirg_. )000- tb/wriL 44.,....A. teehez,- I <br />1-- E <br />16. International Shipments Import to U.S. n Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />Ce 17. Transporter Acknowledgment of Receipt of Materials TRANSPQRTE Transporter 1 Printed/Typed Name <br />- <br />AIJ 001401x- _id <br />Signature Month Day <br />4t44. 62 I 5 - 1 1( <br />Year <br />21- <br />Transporter rinted/Typed Name Signature Month Day <br />(xi (3 <br />Year <br />1:1- *----- DESIGNATED FACILITY ----.• ' 18. Discrepancy <br />Discrepancy Indication Space 0 Quanlity Type El Residue Partial Rejection E Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U S. EPA ID Number <br />Facility's Phone: <br />113c. Signature of Alternate Facility (or Generator) Month Day War <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />tk' 1 U 1 <br />2. 3. <br />20. Designated Facility Owner or Operator: Certifica on of receipt of hazardous materials covered by the manifest except ncted in Item 18a <br />P ri ed <br />ntediTYPCIPITtC) <br />Signature <br />PaGE 0 I ) <br />Meplh Day Yeats <br />12- <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. so-