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Please print or type.(Form designed for use on elite(12-pitta)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I I.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number fWASTE MANIFEST U+_ F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Y L,E INLAND -400 W- CA.LPICO POAD, TRACY, CA. 93375 Generator's Phone: 1 ,. 8. ransporter 1 ompany ame 02 U.S.EPA ID Number a p �❑ a T l F!!'?'Al. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Cd FAN KMBORS 18VITTONWTUM, LLS tM WEST WKERN RD. BUTTONWILLOW, CA 93206 CAD9BG675�75 Facility's PhDne: 661-762-6200 ems! ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 13.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any}) No. Type Quantity Wt.fvol. 0 1.RON 12CRA HA.ZARDOVS WAS'TSLIQUID N.O.S. (INK r WA Tr K SOLVABLE) Z 2. W C9 3. 4 14.Special Handling Instructions and Additional Information 15. GENERATOR'S10FFEROR'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 labeledlplacerded,and are in all respects in proper condition for transport acconbrig 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 44 CFR 262.27(x)(if I am a large quantify generator)or(b)(if I am a small quantity generator)is true. Generator eror's PrintedfTyped Name Sgirrature Month Day Year J 18.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit Z Transporter signature for exports onl Date leaving U.S.: 17.TransporterAcknowledgment of Receipt of Materials Transported PrintedlTypedName Signature Month Day Year p Q[77;53Ter 2I rintedffViped Name Signature Month Day Yea, 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b"Alternate Facility(or Generator) US-EPA ID Number J_ V a Facility's Phone: 18c.Signature o(Allemate Facility{or Generator} Month Day Year a z 19.Hazardous Waste Report Management Method Cedes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedrryped Name Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY