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E Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) E Form ADDroved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY i UNIFORM HAZARDOUS 1.Generator ID Number 2. Page 1 of 3. Emergency Response Phone4.an ng Number WASTE MANIFEST r,11%1,000364443 1 877—.737 P JJK 00 4248 .5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) lx^'�' Aatto Paytr. -A-049 1049 S "RAy r.A 9.,S206 Generator's Phone: �4q 4 A i-,) -"?`t71 6. Transporter I Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. ftignated Facility Name and Site Address U.S. EPA ID Number I V-.00 1601 VXOCT?�'g'A 'hit, '1201.5 Facility's Phone: 61 0 i 1 377 4 `?:a 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 11. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt./Vol. 1. 0 7� L 3. 4. 141rqieVlinKT Vnstruction and Additi nal Inforrpatil Vk CVX�E.11 3234999 JS 15. GENERATOR'S/OFFEROR'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 labelediplacarded, 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(a) (If I am a large quantity generator) op(b) (If I am a small quantity generator) is true. qeneratoes/Offemes Printed/Typed Name- Signature' Month Day Year -j 16. International Shipments El Import to U.S. El Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials Transport r 1,Pdnjedfryped Name ✓ Signature Month Day Year 7/ 0 CL Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space 0 Quantity E]Type ❑ Residue❑ Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facility. Phone: Uj 18c. Signature of Alternate Facility (or Generator) Month Day Year !R Z I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLI 1 2. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY