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Please print or type, (Form designed for use on elite (12 -pitch) typewrite UNIFORM HAZARDOUS 1 1 . Generator ID Number WASTE MANIFEST T denerators Name and MalhgAddres, rnwm; 0. ton, CA Generators PhoQe2W'1144W' UOMPallyNalre Owmillug 2. Page I of 3. Emergency Response Phone Form Approved. OMB No. 2050-0039 *l" Numr, Number b'c'; "2 9 F L E CAVA "W17VAir r't tit 11649V 7 15. (iENERAMR!S/OFFERORSqERTIFICATION: I hereby declare that Me contents of this consignment am fully and accurately described above by the proper shipping name, and are classiled, packaged—, marked and tabekdpiacarded,.and are in all respects in proper condition for transport according to applicable International and national governments! reostiOns. If export shipment and I am the Primary Exporter. I ceVy that the contents of this consignment OGnfOFm to the terms of the allachod EPA Acknowledgment of Consent. t certify that the waste minimization statement Identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (f I am a small quantity generator) is We. GeneralorsmaroesparxectlypeoNsme signature Wrth Uay I 16 Intarnallonal Shipments F] Impart I. U.S. ❑ Export from U.S. Part of entrytexit: Tfansporter signature fore ortsonly): Date Wving_U.S,: 17. TransporterAGIolowledgment of Receipt of Iftedals Transportar 1 Printec[Qyped Name Signature month Day 71 Month Day Year 18. Discrepancy 188. Discrepancy Indication Space E] o..niity ❑ Type El Residue ❑ Partial Reji.,Uon � njfestRelerenoe Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facfl SEP 0 8 2015 _Vs Phone: c. Signature ofAUemate Facility (orGeoeralDr) paV Z 19S2 P', L . Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 1. 2.3. 4. 20. Designated Facility Owner or OperqkDr: Certification of receipt of hazardous materials covered by the manifest except as noted In Item, 18a Printed/Typed Name ignatwe Month Day Year EPA Form 8700-22 (Rev. 3J05) Previous editions are obsolete. TRANSPORTER'S COPY F'o P"5i", 1'k 5731'itw I Wr-*'t'-A* I (Axn 'Y'71, IFR Facile sPh,,oNne M.Zx, 98. HM 9b. U.S. DOT Desarlpfjoh (Including Proper Shipping Name, Hezard Class. ID Number, and Packing Group (it any)) Ia. Containers 111. Total 12. Unit No. Type Quantity Wt.Ml. 13, Waste Codes X ILIpq . (; r't tit 11649V 7 15. (iENERAMR!S/OFFERORSqERTIFICATION: I hereby declare that Me contents of this consignment am fully and accurately described above by the proper shipping name, and are classiled, packaged—, marked and tabekdpiacarded,.and are in all respects in proper condition for transport according to applicable International and national governments! reostiOns. If export shipment and I am the Primary Exporter. I ceVy that the contents of this consignment OGnfOFm to the terms of the allachod EPA Acknowledgment of Consent. t certify that the waste minimization statement Identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (f I am a small quantity generator) is We. GeneralorsmaroesparxectlypeoNsme signature Wrth Uay I 16 Intarnallonal Shipments F] Impart I. U.S. ❑ Export from U.S. Part of entrytexit: Tfansporter signature fore ortsonly): Date Wving_U.S,: 17. TransporterAGIolowledgment of Receipt of Iftedals Transportar 1 Printec[Qyped Name Signature month Day 71 Month Day Year 18. Discrepancy 188. Discrepancy Indication Space E] o..niity ❑ Type El Residue ❑ Partial Reji.,Uon � njfestRelerenoe Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facfl SEP 0 8 2015 _Vs Phone: c. Signature ofAUemate Facility (orGeoeralDr) paV Z 19S2 P', L . Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) 1. 2.3. 4. 20. Designated Facility Owner or OperqkDr: Certification of receipt of hazardous materials covered by the manifest except as noted In Item, 18a Printed/Typed Name ignatwe Month Day Year EPA Form 8700-22 (Rev. 3J05) Previous editions are obsolete. TRANSPORTER'S COPY