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T SE:V'F'W 2 l�:��LS176�i i"4-"Mt 5 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 't Form Approved.OMB No.2050-0039 F- UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest}Tracking Number WASTE MANIFEST f-A L 0 0 G 2 t3 4 9 2 � i800s#�t_j1s r 11 ©V J��9 305 F L E r 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) .140 5.fir.Way SME 5trrArt an CA f4fi20q Generators Phone: Q.0%rT 12A+G13 6.Transporter 1 Company Name U.S.EPA ID Number Clean Mastear.,Envirotwtnontal gee,.if +,Inc 7.Transporter 2 Company Name U.S.EPA ID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number Clean 4ilrbvrs S&A W.- ra 10211-hem essa Road an 1f,.�A 1'_.A "R i, Facility's Phone: 6-4 1 2 9i7 s ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1' 14A3 9Z NVAR000S WASTE,t.'Qt iD.R.W;_(Eij:NZ'ENE, 6�y a c�,3�DL1t41;�Z. .f�� I.L{T ,.r4,i W Z 2. W C7 3. 4. ( 14.Special Handling Instructions and Additional Information 15- GENERATOR'SIOFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generators/Offerors Printed/Typed FtName / Signature J Month May Year -j 16.International Shipments / y. i= ❑Import to U.S. ❑Exportfrom U.S.! Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials W Transporter 1 Printed/Typed Name Signature Month Day ear �I -:7 fit, Q Transporter 2 Printedflyped Name Signature t Month Day Year iY F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q � Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) .� 1. 2. r 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(R,,.. fi e.la,y.3-0{5) Previous editions are obsolete. 00Y 41;t la7aUars Cad'i dw aapria1?@19,?o f�qj t'r fed and WIH? A pl thewasl ,3 the z ilprc-alar is Alppiq%. GENERATOR'S INITIAL COPY