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Please print or . Form des' ned for use on elite 12-pitch) ' r.y Form,Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number' fof 3 EmiFg9Mtgf Phone 4.MardfestTrraber WASTE MANIFEST )A, f1i;t .'3 ar r#* 30-09931. G 5.Generator's Name and MaWing Address Yltldiess(if different than mailing address) AWOckii:Jllf+t VALi-EY WA4i f k (rft.. 7u ra t$K)X 340 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number tS;fiiCC6tICA f'llhl:.LCY'rVAf k t-44 ,1,14C ,'At ift�il� i�Ci 7,Transporter 2 Company Name U.S:EPA ID Number 8.Designated Facility Name and Site Address EPA IDNumber 53 ad Oka 45 iRA tr .ter s > CAL 000190'& Facility's Phone: �! 9a. 9b.U.S.DOT Desetip(l n(including Proper Shipp Mime,Hazard Class,ID Number, 10.Containers 11.Tots) 12.Unit HM and Packing Group{deny)) 13.Waste Codes No: Type Quantity Wt.Nol- 1Z 1 Nf114-11141C,41A 1 A;IAR",#v.WksT1a.S:lfxtitC) y i i 0 riJ#^'F?t3 tilt`Y WAY",l d i WQQ �1 i 2 UJIE 3. S 4. I _... 14.Special Harx2i g instructions and Additional Information PROP It:I-#ii iii t[1f;Ir)1ti ! mct oh.;,4NCY#Y.rf,:'C f str-VF'' (i13 15. GENERATOR'SIOFFEROR'S CERTIFICA71ON: I hereby declare that the contents of this consignment are fully and accurately described above by Hie proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemalional and national goyernmental regulations.tf 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 barge quantity generator)or(b)(di am a small quantity generator)is true. Generator'slOffemes Printedfryped Name SignatureMonth Day Year J 16.International Shipments r- ❑Import to U.S. ❑Export from U. Pat of entry/exit• z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acimowledgmerlt of Recelpt of Materials Transporter 1 Pri00- d/ryped Name Signature Month Day Year /. Q Transport 2 Pdn pe .me Signa Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El 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: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 18.Hazardous Waste R!L Management Method Codes CO.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 12- 3. 4. � 3 20.Design ted F dWty Owner or Operator.Certmcation pl of hazardous materials covered by the manifest except at nQed 1 Printed/Typed Name Signal= Month Da)�Y- Ye EPA Form 8700-22(Rev.3 051 Previus editions are snlet .