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CC: MANIPEBT BOOK!A/P c6*-7As-z ORlG: y OMB NoJw Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approv6d. .2050-0039 } UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST F.,1- 4 GB F 5.Generator's Name and Mailing Address Generator's Sit,Address(if different than mailing address) 1'lt> F fvi':+,Y ,44c, +NTE:�:::�t,CA 7 Generator's Phone: � � , 6.Transporter 1 Company R4Re U.S.EPA ID Number SHOP W/t1 ARV8 S01-011( 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number f;'�141-f AW-K- t-COCKNJA,l.l.ti;. 1't e56 T'E R(XX . Facility's Phone: .T# i 't #`A0 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' t-0i(.#1-R(OttA t"i >ARIX)4.:6'W TES.UD COO 223 36 Z 2. w c� 3. .J 4. 4.Special Handling Instructions and Additional Information WOR 1,-F-a I.110N.2•-'!' 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/Offer Prinnled/Typed Name Signature Month Day Year r � - -J 16.Internatio-n#Shipmerits Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year O CL N r ZZ QTransporter rinted yped Nant Signatu Mc ay H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U tai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. Notice:New federal form. State of California requires generator to photocopy 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a and mail to DISC within 30 days: Printed/Typed Name Signature P.O.Box 400,Sacramento,CA 95812-0400 EPA Form 8700-22(Rev.3-05) Previous editions are obsolei..