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M� o0 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form-Appto4ed.0 No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CLU111111CXi/, 800-424-911Cyt f'C:Ct,: 0, 09776865 JJ K 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) E4- r c/o()T£>C, t.{cx t`N*Rd ,r," iftvf Fre w4Carep Rd x'.13. liUK Niru` -Stmkinn CA R."I5 J CA Generator's Phone: 800.V0-3V/2-IV) 6,Transporter 1 Company Name U.S.EPA ID Number ;-*uCtom i';tie 1, . 7.Transporter 2 Company Name U.S.EPA ID Number PISC E.n%mronnlelltti4l SeeioevwPomona•LI` CAf1 0A-iA4�iu,,r: 8 Designated Facility Name and SbAddtea U.S.EPA ID Number CMVTI6CM l0ar r+±C)+ 2w5 hast IF 60 rias LAtive y NV 89408 Facility's Phone: 715-575-2M 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)) 13.Waste Codes No. Type Quantity Wt.Nol, O 1' UN 10 11,Waoto tk+tans,2.1,Rha(ClWl) si C)Of�1 w z 2. L O 3. 4, 14 Special Handling Instuetionsand Additional Information -Ndor: 115 1,t' ,*In Cab-Weir appropriate por+sonat prote"ive eoupment when handling i(2nt�3) Job0 5761 L kw*2014-11-007 P 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. Generator's/Offeror's Printed,'Typed Name Signature Month Day Year 16.Intemational Shipments F— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials of Transporter 1 Printed/Typed Name Signature Month Day Year O a M Transporter 2 Printed/Typed Name Si nature Q 9 Month Day Year o: 1-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ I ❑Full Rejection ❑Residue Partial Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) IQ; Month Day Year Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) w 0 1 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY