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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB Na.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Pagel of 3.Emergency Response Phone " " -4 anifest Tracking Number WASTE MANIFEST �✓' o u U :7 � FLE 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 00;NVa115k'o Road Generator's Phone: 6 Transporter 1 Company Name U.S.EPA ID Number 1-4 A U U 932 i sli 7.Transporter 2 Company Name U.S.EPA ID Number 8;agsj�naFak)y Na��afrdp ¢ddess. U.S.EPA lD Number ,an Jolae,CA,X5135 Facility's Phone: = } 4 9a. 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)) No. Type Quantity Wt.Nol. 13.Waste Codes 1 RO .S.2.1,UN 1950 � w �u � ctakt��y W LU UJ 2;,tCyr. -iZARDOUS 4'4dAtSTE LIQUIDS,(USM-0 Qui,NONE � c� nl ,,. - 3 r: €i'�A 1-+ ,,;=ARDMS— V+rlASTE UCXJIDS,(P0L.i'9XY s 1 RCRA HAZARDO` S IOMSYE SOLIDS,(OIL,AARSa0PBSNTI, 14,Spacial Handling Instructions and Additional Information C H200521 C -,*121 612M12 2. CH240507 (-4X ray 0-11 4 CH2'I3CI612 � 413 V m 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this censignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneratorslOfferorsPrinted/Typed Name Signature on ay Year J 16.Intemational Sfripmeals ❑Imporo U.S. LlExportfrom U.S. Port of entryfe' Z Transporter signature far ex orf r Date leaving U.S.: LM 17.TransporterAcknowledgment of Receipt of Materials Transporter 1 PrintedfTyped Name ignatu Month Day Year OCL , Q Transporter 2 Printedrfyped Name Sgnature Month Day Year t' - 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 16b.Alternate Facility(or Generator) U.S.EPA 17 Number J U a �- Facility's Phone: Lt 18c.Signature oiAtemate Facility(or Generator) Month Day Year Q 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) W 2. C, � t 'F ,,, I r �1 3. 4 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1&a, PrintedfTyped Name yyy ' Si at Mo� D� YearI EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. .:' 1t '_:• +a;r,rewr •;-3,. rte_ r aF:.,�wEr a!x;.PT the..a Ste mi a�I,,rXC, +s sharpinq DESIGNATED FACILITY TO GENERATOR